Two Food Elimination Diet (2FED) for EoE

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

pdfASCIA_PCC_Dietary_Guide_EoE_2FED_2021v2.pdf225.33 KB

The 2FED diet eliminates the two most common trigger foods for EoE – cow’s milk (dairy) and wheat

Diet Instructions

  1. This diet plan outlines how to follow a diet free from cow’s milk (dairy) and wheat. The diet involves strictly avoiding all foods and drinks that contain cow’s milk (dairy) 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, egg, 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 or milk. In Australia and New Zealand, food manufacturers must declare the presence of any cow’s (and other animal) milk (dairy), 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) or wheat as an ingredient but have a “may contain ______” style statement are safe to include on this diet.

Cow’s milk protein

The following foods and ingredients contain cow’s milk protein and should be avoided:

A2 milk

Dried milk

Low fat milk

Acidophilus milk

Dried milk solids

Malted milk

Butter

Evaporated milk

Milk

Buttermilk

Fat-free milk

Milk derivative

Casein/caseinates

Ghee

Milk powder

Cheese

Butter oil

Milk protein

Cheese powder

Butter fat

Milk solids

Condensed milk

Hydrolysates (casein, milk protein, whey)

Non-fat dairy solids

Cottage cheese

Ice cream

Non-fat milk solids

Cream

Infant formula – cow’s milk based including partially hydrolysed (HA) formula

Skim milk

Cultured milk

Kefir

Skim milk solids

Curds

Lactalbumin

Sour cream

Custard

Lactoglobulin

Whey

Dairy solids

Lactose free milk

Yoghurt

Note: Other animal milks such as goat, sheep, camel, buffalo products are too similar to cow’s milk (dairy) products, so they should not be used as substitutes. Check labels on all foods.

The following foods may contain cow’s milk protein unless the label says otherwise and need to be avoided:

Cocktails (alcoholic and non-alcoholic)

Breads, breadcrumbs

Caramel or butterscotch desserts

Biscuits, cakes, pastry

Breakfast cereal

Chocolate

Bottled water that is flavoured or protein enriched

Canned spaghetti

Probiotic drinks

Confectionary

Instant mashed potatoes

Processed meats

Drinking Chocolate

Malted milk powder

Protein powders

Gravy

Margarine

Salad dressings

High energy foods and powders with added protein

Milk ice blocks

Snack food

High protein fruit juice drinks

Non-dairy creamers

Soy cheese

Icing

Nougat

Soups

Infant rusks/rice cereals

Pasta sauces

Sports drinks

Wheat

The following foods and ingredients contain wheat and should be avoided:

Atta flour

Graham flour

Wheat

Bulgar

Kamut

Wheat bran

Burghul

Matzoh

Wheat flour

Couscous

Seitan

Wheat germ

Cracker meal

Semolina

Wheat meal

Durum

Spelt

Wheat starch

Farina

Tabouleh

Wheat berries

Gluten

Triticale

 

Check labels on the following foods to see if they contain wheat and if they do, avoid them:

Baked goods

Flavouring (natural/artificial)

Pastry/tarts

Battered foods

Hydrolysed vegetable protein (HVP)

Playdough (use wheat free)

Beer

Ice cream cones

Processed meats

Biscuits

Icing sugar

Rusks

Bread (other than gluten free)

Instant drink mixes

Sauces/gravy mixes

Breadcrumbs

Liquorice

Soy sauce

Breakfast cereal

Lollies

Soups

Cakes/muffins

Malt, malted milk

Snack foods

Canned soups/stocks

Meat/seafood substitutes

Starch

Cereal extract

Multigrain or wholemeal foods

Stock cubes

Coffee substitutes

Mustard

Surimi

Cornflour (from wheat)

Pancakes/waffles

Vegetable gum/starch

Donuts

Pasta/noodles

 

Foods to include whilst following the 2FED diet for EoE

Ingredients listed in the table below do not contain cow’s milk or wheat proteins and are safe to eat whilst following the 2FED diet for EoE.

Wheat

  • Glucose
  • Glucose syrup
  • Glucose powder
  • Dextrose
  • Caramel colour
  • Monosodium glutamate

Milk

  • Cocoa butter
  • Cream of tartar
  • Lactic acid - some lactic acid starter cultures may however contain milk (check label)
  • Lactose in medication - lactose is the sugar contained in cow’s milk and the pure sugar form is used in medications
  • Sodium or calcium lactate
  • Sodium or calcium stearoyl lactylate

Note:

  • Lactose free products should not be consumed as part of the 2FED diet as they still contain normal amounts of cow’s milk protein

Cow’s milk (dairy) alternatives

Instead of:

Use:

Cow's milk infant formula for a child less than one to two years of age

Breast milk or appropriate formula as advised by your child’s medical specialist.

Cow's milk for children over one to two years of age and adults

Soy, rice, oat, nut, pea protein-based drinks. Choose one with 120-160 mg calcium per 100 ml. If tolerated calcium fortified soy milk is preferred due to higher protein and fat content.

Yoghurt

Soy, coconut, nut or other plant based, custards & chia puddings,  homemade desserts with milk substitute.

Note:

  • Some products contain a small amount of cow’s milk protein.
  • Check labels carefully and ideally choose one with added calcium.

Cheese, sour cream

Plant based.

Note: Some soy cheeses contain cow’s milk protein. Check the label carefully.

Ice cream

Plant based Check the label carefully.

Butter and margarine

Oil or milk free margarine

Cream and condensed milk

Plant based

Chocolate

Plant based

Considerations for infants and young children

If your child will not drink the milk substitute, a dietitian can advise how to encourage your child to accept it, or how to supplement the diet with essential nutrients such as calcium, energy and protein.

It is important to have an adequate calcium intake, as recommended in the following table.

Recommended daily intakes of calcium

AGE

CALCIUM (mg)

1 – 3 years

500

4 – 8 years

700

9 – 11 years

1000

12 – 18 years

1300

Men 19 - 70years

1000

Men >70 years

1300

Women 19 - 50 years

1000

Women >50 years

1300

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 alternatives

The biggest challenge when avoiding wheat is finding alternative breads, cereals and pasta. The following table outlines some substitutes.

Instead of:
Use:

Breads, cereals, pastas made from wheat flours and grains.

Breads, flours, cereals, pastas made from:

Amaranth

Arrowroot

Barley

Buckwheat

Chickpea (besan)

Coconut

Corn (maize)

Gluten-free flours

Lentil

Lupin

Millet

Oat

Pea

Polenta

Potato

Psyllium

Quinoa

Rice

Rye

Sago

Soy

Sorghum

Tapioca

Snacks such as muesli bars and muffins

Rice and corn crackers/cakes, gluten free savoury biscuits and crackers, gluten free muesli and snack bars

Treats such as biscuits and chocolate

Plain salted potato chips, corn chips, rice chips, and gluten free sweet biscuits

Beer (alcoholic and non-alcoholic)

Brands made from hops or barley. Gluten free beer.

Meal and snack ideas

Breakfast

Oat porridge made with calcium fortified alternative milk or yoghurt (check label for wheat or gluten traces)

Gluten free cereal with calcium fortified alternative milk or yoghurt

Gluten free packet mix or home-made pancakes with wheat and milk substitutions

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

Cooked breakfast options such as egg, wheat free baked beans, tomatoes, mushrooms, bacon, wheat free sausages, 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

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

Homemade crumbed chicken or fish using gluten free crumbs

Risotto/fried rice dish

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

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

Gluten free pizza base and toppings (use soy or coconut cheese)

Meat or fish-based curry and vegetables with rice, rice noodles or millet based couscous

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

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

Rice paper rolls

Sushi (check ingredients)

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

Baked potato or sweet potato with various toppings

Baked beans, egg (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, 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 or avocado

Plain potato chips

Jelly

Salsa or hummus dip with rice crackers or vegetable sticks 

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

For patient/consumer support organisations go to www.allergy.org.au/patients/patient-support-organisations 

© ASCIA 2021

ASCIA is the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand.

ASCIA resources are based on published literature and expert review, however, they are not intended to replace medical advice. The content of ASCIA resources is not influenced by any commercial organisations.

For more information go to www.allergy.org.au

To donate to immunology/allergy research go to www.allergyimmunology.org.au

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