Dietary Approaches in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated, non-IgE-mediated food allergy and a leading cause of dysphagia and food impaction in adults, with rising prevalence worldwide. Diagnosis requires ≥15 eosinophils per high-power field on esophageal biopsy after exclusion of other causes of gastrointestinal eosinophilia. Food allergens, principally milk, wheat, eggs, legumes and seafood, drive the inflammatory process, and treatment options include proton pump inhibitors, topical corticosteroids, biologic agents and endoscopic dilation for stricturing disease. Among these, dietary therapy is the only approach that removes the causative trigger rather than suppressing the inflammatory response, making drug-free, sustained remission achievable. Elemental diets achieve the highest histological remission rates but are poorly tolerated in practice; empiric elimination following a step-up strategy, starting with one or two foods and escalating in the absence of response, is more practical for most adults. Conventional allergy testing cannot reliably identify food triggers in EoE and is not recommended for this purpose. Reintroduction of the trigger food leads to relapse, making long-term adherence essential, and not all patients are suitable candidates: repeated endoscopy, dietary restriction, quality of life impact and the risk of avoidant restrictive food intake disorder (ARFID) are barriers that must be weighed before recommending this approach. This review summarizes the available dietary approaches in adult and adolescent EoE, covering empiric elimination strategies and their efficacy, allergy test-directed diets, patient selection, the role of diet alongside other treatments, and nutritional adequacy and adherence.