Research Horizons


Eliminating Just One Food Trigger Can Improve Life for People With EoE

Eosinophils live in the segments of the gastrointestinal tract below the esophagus, including the stomach and small and large intestines, helping us monitor and combat any outside threats that enter our bodies through our mouths. However, high levels of eosinophils, called eosinophilia, in the esophagus indicates disease, such as a rare, chronic condition called eosinophilic esophagitis (EoE) that is often triggered by food or environmental allergens.

Treating and managing EoE currently uses steroids or elimination diets, in which disease-triggering foods are excluded from the diet. Although steroid use has known side effects, many people chose steroids because elimination diets can be challenging. Food triggers are specific to each individual, making eliminating foods a trial-and-error process of either 1) eliminating all foods, called an elemental diet, and then adding foods back in one at a time, or 2) eliminating specific foods one at a time, called an empiric elimination diet.

Three or more months after each elimination or addition to the diet, the disease activity is checked to determine whether that food was a trigger or tolerated for the individual’s EoE. The goal is to eliminate the least foods necessary to keep EoE activity in check. Yet, the path to an effective personalized elimination diet can be time-consuming and costly and challenging in terms of diet adherence and effects on quality of life.

Our physicians and researchers explored how to improve this trial-and-error-process by comparing eliminating a single food, cow’s milk, with eliminating six commonly allergenic food groups—cow’s milk, egg, wheat, soy, fish and shellfish, and tree nuts and peanut. The findings–published Feb. 28, 2023, in the Lancet: Gastroenterology and Hepatology–are the first from a large, randomized, multi-center trial and were surprising.

“The primary hypothesis of this trial was that the standard six food elimination diet (6FED) would be superior to the dietary elimination of milk alone (1FED) in achieving histologic remission in adults with EoE,” says Marc Rothenberg, MD, PhD, senior author of the study, director of the Cincinnati Center for Eosinophilic Disorders at Cincinnati Children’s, and principal investigator of the Consoritum of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). “We were surprised when we failed to demonstrate this. Instead, we found that both diets were similarly effective across multiple metrics. We also found that for the small number of 1FED non-responders in our study that then opted to try 6FED, almost half achieved histologic remission. Taken together, we concluded that it is reasonable to start with the elimination of milk alone – which may be easier for patients – and “step-up” to a more restrictive diet, such as the 6FED, if needed.”


In addition to Kliewer and Rothenberg, Cincinnati Children’s co-authors included J. Pablo Abonia, MD, Margaret Collins, MD, Lisa Martin, PhD, Vincent Mukkada, MD, and Tetsuo Shoda, MD, PhD.

This work was supported by NIH grants (CEGIR, U54AI117804; Data Management and Coordinating Center; U2CTR002818; Digestive Health Center P30 DK078392 [Gene and Protein Expression Core]; K99/R00 AI158660; R01ES031940, R01DK132001, R01AI139126, R01AI140133, R01ES031940, R01AI045898, R01Al148138, and R01AI24355; R21 DK122297 and R21AI139438; U19AI070235

Learn More

Read the NIH Press Release

Read the RDCRN Interview

View Dr. Rothenberg’s presentation for Rare Diseases Day

Read more about research of the Cincinnati Center for Eosinophilic Disorders and Rothenberg CURED Lab


Publication Information
Original title: One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial
Published in: The Lancet Gastroenterology & Hepatology
Publish date: Feb. 28, 2023
Read the Findings

Research By

Kara Kliewer, RD, PhD
Kara Kliewer, RD, PhD
Registered Dietitian, Cincinnati Center for Eosinophilic Disorders
Marc Rothenberg, MD, PhD
Marc Rothenberg, MD, PhD
Director, Division of Allergy and Immunology

The Rothenberg CURED Research Laboratory, supported by the Campaign Urging Research for Eosinophilic Diseases (CURED), is focused on elucidating the mechanisms of allergic responses, especially in mucosal tissues such as the gastrointestinal tract and lung.