Dietary Guide - Four Food Elimination Diet (4FED) for EoE

This document has been developed by ASCIA, the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand. ASCIA information is based on published literature and expert review, is not influenced by commercial organisations and is not intended to replace medical advice. For patient or carer support contact Allergy & Anaphylaxis Australia, AuSEE or Allergy New Zealand.

Eosinophilic oesophagitis (EoE) happens when white blood cells (called eosinophils) build up in the lining of the oesophagus, which is the tube that connects the mouth to the stomach. This can be the result of an allergic reaction to food or the environment. Most cases of EoE are seen in people with other allergies such as allergic rhinitis (hay fever) and asthma. It is estimated to affect around one in 1,000 people (children and adults), and the frequency of EoE appears to be increasing. The reasons are unclear, but it is known that allergies of all types have become more common.

More information about EoE can be found on the ASCIA website:

www.allergy.org.au/patients/food-other-adverse-reactions/eosinophilic-oesophagitis

ASCIA PCC Dietary Guide EoE 4FED 2023217.28 KB

The 4FED diet eliminates 4 common trigger foods for EoE - cow’s milk (dairy), soy, egg and wheat

Diet Instructions

1. This diet plan outlines how to follow a diet free from cow’s milk (dairy), soy, egg and wheat. The diet involves strictly avoiding all foods and drinks that contain cow’s milk (dairy), soy, egg and wheat even in very small quantities.
2. This diet is to be used for 8 to 12 weeks as a trial to see if avoiding certain foods will help reduce symptoms. You should regard this diet as a test to see if foods are making symptoms worse and not necessarily a long term treatment.
3. You will be asked to complete diaries recording foods eaten and details of any symptoms whilst following this diet.
4. The effect of the diet will be assessed by symptoms and/or a repeat endoscopy (a procedure to look inside the body with a small tube with a camera and light attached), and biopsies (samples of cells) of the oesphagus are taken.
5. Each food will then be reintroduced one by one. Introduction of foods will be discussed in detail by the doctor and dietitian at follow up appointments.

What foods can be eaten?

If you have existing food allergies it is important to continue to avoid those foods whilst following this diet for EoE. Otherwise, all plain meat, fish, chicken, legumes, non-wheat grains, fruits, nuts, seeds and vegetables can be included. Your specialist may recommend excluding all gluten containing grains (wheat, barley, rye and oats).

What about packaged foods?

Many packaged food products will contain ingredients made from wheat, soy, egg or milk. In Australia and New Zealand, food manufacturers must declare the presence of any cow’s (and other animal) milk (dairy), soy, egg, wheat and other gluten containing grains however small the amount. It is important to check package labels, including ingredients lists carefully, and avoid products with any of the ingredients in the following tables.

What are “may contain traces of” statements?

These statements are voluntary and used by manufacturers to indicate that the product may be contaminated with food allergen ingredients through processing and packaging. Products that do not directly contain cow’s milk (dairy), soy, egg or wheat as an ingredient but have a “may contain ______” style statement are safe to include on this diet.

The table below lists foods and ingredients that contain cow’s milk, soy, egg or wheat protein and should be avoided.

The table below lists ingredients that do not contain milk, egg, soy or wheat proteins and are safe to include whilst following this diet.

What foods can be included instead?

Cow’s milk substitutes

Cow’s milk can be an important source of energy, protein and calcium in the diet, especially for developing infants and children. Appropriate substitution is essential to ensure adequate growth and development (in children) and sufficient intake of calcium.

Rice, oat, nut, pea or coconut-based drinks are NOT suitable as a drink for children under 1 year of age due to inadequate amounts of energy, fat and protein. For children over 1 year of age these drinks should only be used after consultation with a clinical immunology/allergy specialist and/or dietitian with experience in paediatric food allergy to ensure your child is getting adequate nutrition.

Summary of cow’s milk and soy substitutes

A calcium supplement may need to be taken if inadequate volumes of milk replacement or specialised formula are taken. Your dietitian will assess this and discuss this with you if required.

Wheat substitutes

The biggest challenge when avoiding wheat as well as egg, soy and milk is finding alternative breads, cereals and pasta. Many wheat free/gluten free breads will contain egg, soy or milk as ingredients. Ask your dietitian about brands of bread or bread mixes that will be suitable.

The table below outlines some alternatives.

Specialty food allergy products

There are many specialised food products that are wheat, soy, milk and egg free. These products can be found in the health food section of the supermarket, health food stores or specialised online allergy stores.

Many of your favourite recipes can be modified to be suitable for use whilst following this diet.

The table below outlines ingredients used in many recipes and the suitable substitute ingredient.

Meal and snack ideas

Breakfast

Oat porridge (check label for wheat and or gluten traces) made with calcium added plant milk (such as rice, oat, almond, pea, coconut)

Gluten free cereal with calcium added milk substitutes

Gluten free packet mix or home-made pancakes with egg, wheat and milk substitute

Wheat free bread with toppings such as honey, jam, nut spreads

Cooked breakfast options such as wheat free baked beans, tomatoes, mushrooms, bacon, avocado with wheat free bread

Smoothie made with fruit, oats, seeds, calcium fortified alternative milk and yoghurt

Fruit or vegetable juice, calcium fortified alternative milk (in coffee or tea)

Lunch and dinner ideas

Plain grilled, BBQ or roast beef, chicken, lamb, fish with salad/vegetables and rice, quinoa, barley or millet based cous cous

Homemade crumbed chicken or fish using egg replacer and gluten free crumbs to coat

Risotto/fried rice dish

Barley, quinoa and other alternative grain based salads and other meals

Wheat free pasta with homemade tomato-based sauce or bolognaise sauce

Gluten free pizza base and toppings (use coconut cheese)

Meat or fish-based curry and vegetables with rice, rice noodles or Millet based cous cous

Rice cakes with hummus, avocado, nut spreads, sliced meats (check ingredients), salad vegetables

Gluten free wraps with chicken, lamb, beef or ham and salad

Rice paper rolls

Tacos or burritos with corn-based taco shells or gluten free wraps

Baked potato or sweet potato with various toppings

Baked beans, (or other cooked breakfast options) on wheat free toast

Snacks

Smoothies made with calcium fortified alternative milk or yoghurt

Ice blocks with calcium fortified alternative milk or yoghurt

Homemade cakes and biscuits

Protein or energy balls made with ingredients such as ground nuts, honey, cocoa, soy free plant based protein powder, dried fruit and coconut

Fresh and dried fruit

Calcium fortified alternative custard, ice-cream or yoghurt with fruit

Plain popcorn

Corn chips, rice crackers with tomato salsa, nut butters or avocado

Plain potato chips

Jelly

Salsa or hummus dip with rice crackers or vegetable sticks

Nuts and nut butters

Note: The food lists included in this document are not exhaustive. People with food allergy should check foods labels each time products are purchased.

© ASCIA 2023

Content updated 2021

Format updated June 2023

For more information go to www.allergy.org.au/patients/food-allergy and

www.allergy.org.au/patients/food-other-adverse-reactions

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