SIX FOOD ELIMINATION DIET (SFED)

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SIX FOOD ELIMINATION DIET

INTRODUCTION The Six Food Elimination Diet (SFED) is a therapeutic dietary intervention designed to eliminate foods that may be causing adverse reactions. The rationale behind the diet is that common food allergens increase toxic burden, compromise the immune system, fuel a chronic inflammatory process and negatively impact quality of life. By eliminating these foods for a period of time, the body can heal and function is restored. Eosinophilic Esophagitis (EoE) is one example of a condition where food antigens cause inflammatory immune-mediated reactions within the body. Most commonly caused by food allergies, EoE is characterized as an abnormal accumulation of eosinophils (a type of white blood cell) in the lining of the esophagus (as seen via upper endoscopy, or EGD, and biopsy). This can lead to a number of feeding-related symptoms in both children and adults, including reflux, nausea and vomiting, dysphasia, food impaction, chest and stomach pain--often leading to nutrition concerns and malnourishment. The SFED is a "first-line therapy" that has been shown to be effective at inducing histologic remission of EoE. Therefore, identifying the foods that are causing this cascade of events is a primary goal of treatment.

DESCRIPTION In the SFED plan, the top allergenic foods are removed for 6-8 weeks (elimination phase), at which time strategic re-introduction trials of individual pure foods will begin (re-introduction phase). Common allergenic foods/food components initially eliminated include:

• Dairy • Eggs • Wheat • Soy • Peanuts & Tree nuts • Fish & Shellfish

All foods and food products containing any of these ingredients must be removed during the elimination phase during which the individual keeps a food and symptom journal. After this period, the timing and choices involved in the reintroduction of foods will depend on the individual’s response to the elimination phase. Most commonly and according to the literature, the foods best tolerated are then challenged one at a time, over a period of up to 6 weeks. Foods within one food group are usually introduced (each food over a period of at least 5-7 days) before moving on to the next food group. Continued monitoring and evaluation will occur during this time, including an EGD after each food group introduced. After proper challenging of each individual food, any foods that have continued to show good tolerance can then be reintroduced to the overall eating plan. Through careful exploration and discovery, it is possible to identify and eliminate some of the foods and food components that are causing adverse reactions within the body, thus, creating a safer, healthier, well-tolerated eating plan unique to each individual. If symptoms remain after the SFED, additional food sensitivities may be present, and a further guided elimination diet may be warranted. The SFED as described above, with the elimination of the top allergenic foods, is the traditional/original diet therapy that has been studied as a beneficial and effective EoE intervention. However, there are variations of the SFED diet that have been researched and used in clinical practice. For instance, the elimination of gluten; and in some studies, all legumes, rice and corn. In addition, some individuals will need a complete SFED while others will benefit from the elimination of some, but not all, foods within this protocol e.g. a 4-food elimination diet (FFED), and lastly, alternative elimination diets such as FODMAPs should also be taken into account, if deemed necessary. This provides further evidence of the importance of having patients work with trained clinicians to determine the best medical nutrition therapy for each individual’s situation and unique needs.

FOODS TO INCLUDE IN SFED EATING PLAN Note: It is important to read food labels for all ingredients

Fruits & Vegetables All Fruits! Examples: Apple, apricot, avocado, banana, berries (blackberry, blueberry, boysenberry, raspberry, strawberry), cherry, citrus fruits (clementine, grapefruit, lemon, lime, tangerine, tangelo), coconut, grape, kiwi, mango, melons (cantaloupe, honeydew, watermelon), nectarine, papaya, peach, pear, persimmon, pineapple, plum, pomegranate

All Vegetables! Examples: Artichoke, asparagus, beet, broccoli, Brussels sprout, carrot, cauliflower, cabbage, celery, cucumber, eggplant, endive, greens (all types), green bean, jicama, kohlrabi, leek, lettuce (all varieties), kale, mushroom (all varieties), okra, onion, parsnip, pea pod, pepper, radish, spinach, squash (all varieties, winter, summer), tomato, turnip, water chestnut, wax bean, zucchini

Whole Grains Notes: Will depend on SFED variation. Pay attention to dairy and egg content in whole

grain products Whole Grains & Whole Grain Flours: Amaranth, barley, buckwheat, corn, oats, millet, quinoa, rice (all types), rye, sorghum, teff, legumes (all types except soy).

All products made with allowed whole grains & whole grain flours: Bars, breads, cereals (hot and cold), crackers, pastas, tortillas and other acceptable grain products

Animal & Plant Protein Animal protein: Beef Game meats Lamb Pork Poultry: chicken, duck, turkey

Plant protein: Beans: adzuki, black, garbanzo, kidney, pinto, white, etc. Lentils: all types

Fats & Oils, Beverages, Condiments/Miscellaneous Fats & Oils: Oils (avocado, canola, coconut, grapeseed, olive, safflower, sunflower) Seeds (chia, flax, pumpkin, sunflower)

Beverages & Condiments: Coffee, tea, non-dairy beverages (coconut, hemp, rice) Herbs + spices (fresh and dried) Mustard Sweeteners: honey, jam/jelly, 100% pure maple syrup, sugar, stevia (limit added sweeteners) Vinegars

FOODS AND INGREDIENTS TO EXCLUDE DURING ELIMINATION PHASE

Any known or suspected problematic foods Read labels for all ingredients, paying special attention to ‘Contains’ and ‘hidden’ sources*

Dairy

Note: Dairy includes cow, goat, sheep milk products Foods Ingredients/Food products

Butter Ice creams Casein Lactulose Cheese Goat’s milk Diacetyl Recaldent

Chocolate products (some)

Pudding Lactalbumin Tagatose

Cow’s milk Sheep’s milk Lactoferrin Whey Cream/Half & half Sour Cream Lactose Custard Yogurt

Eggs

Foods Ingredients/Food products Baked goods Marzipan Albumin Lysozyme Bar drinks Mayonnaise Globulin Ovalbumin Eggs Meringue Lecithin Ovovitellin Egg substitute Some pastas Eggnog Pudding/custard Ice creams Surimi Marshmallows

Wheat Note: Will depend on SFED variation

Foods Ingredients/Food products Bulgur Matzo Bars Flours Couscous Seitan Biscuits/rusk Flour tortillas Dinkel Semolina Bread/bakery Matzo Durum Spelt products Pasta Einkorn Starch/Dextrin Cereals Pita Emmer Triticale Cookies Pizza crust Farina Wheat Flatbread Stuffing Faro Wheat berry Kamut Wheat bran

Wheat germ

Soy

Foods Ingredients/Food products

Edamame Soy sauce Hydrolyzed Vegetable Protein (HVP)

Soy lecithin

Miso Tamari Monosodium Glutamate (MSG)

Soy Protein

Natto Tempeh Soy fiber Textured Vegetable Protein (TVP)

Soy beans Tofu Soy flour

Peanuts & Tree Nuts

Foods Ingredients/Food products All nut butters Peanut All peanut and

tree nut products

Nut pieces

Almond

Pecan

Nut meal, meat Nut paste

Cashew

Pine nut

Nut milk Peanut butter

Chestnut Pistachio Nut oil, butter Peanut oil Hazelnut Praline Lychee

Walnut

Macadamia

Seafood: Fish/Shellfish Note: Check Seafoodwatch.org for safe and sustainable fish

Foods Ingredients All Fish/Shellfish Tuna Bouillabaisse

Clam juice Pollock

Examples: Crab Fish sauce Seafood Cod Krill Fish stock flavoring Haddock Langostino Imitation

crab/lobster Surimi

Halibut Lobster Mahi-Mahi Oysters Salmon Sardines Tilapia Shrimp

HELPFUL TIPS Keep it simple: Choose foods as close to their whole, pure, natural state with as

few added ingredients as possible. Any added ingredients may contribute to a more muddied picture of individual response. The simpler the preparation and overall plan, the less complicated it will be to determine any possible adverse reactions. Try to minimize any additional lifestyle changes or life stressors especially during this time.

Read food labels, be a detective: Along the lines of keeping it simple, be sure to read food labels! Whole foods without labels are preferred, for example, fresh produce. Some foods with labels are okay, but be sure to look for added sugars, fillers, emulsifiers, etc. and find a healthier option.

Plan + Prepare: Plan meals and snacks ahead of time. Have prepared foods readily available to grab and go. Bring food along when "on the go" to avoid 'emergency' situations.

Track your foods and symptoms: Write down each food consumed including time of day, associated symptoms and other important details. This record is very important, and will help when assessing tolerance as well as trouble-shooting, as needed. You can use a food and symptom app such as http://skygazerlabs.com/wp/.

Hydrate! Maintain an optimal level of hydration by drinking water and other acceptable beverages. As a general guideline, aim for at least 2-3 liters daily or 1/2 ounce per pound of body weight. Additional fluid may be needed during the elimination phase, due to the release of fluids that are associated with food allergies/sensitivities. Check the color of urine (light straw color) and use thirst as an indicator of optimal hydration status.

PERSONAL NOTES The following are additional customized nutrition recommendations to meet your specific needs:

REFERENCES + RESOURCES American Academy of Allergy, Asthma & Immunology. Eosinophilic Esophagitis. https://www.aaaai.org/conditions-and-treatments/related-conditions/eosinophilic-esophagitis American Partnership for Eosinophilic Disorders. About EE. https://apfed.org/about-ead/what-is-an-eosinophil-associated-disease/ Doerfler B et al. Practical approach to implementing dietary therapy in adults with eosinophilic esophagitis: the Chicago experience. Diseases of the Esophagus. 2014. Gomez-Aldana A et al. Eosinophilic esophagitis: Current concepts in diagnosis and treatment. World J Gasteroenterol. 2019; 25(32):4598-4613. Kagalwalla AF. Dietary Treatment of Eosinophilic Esophagitis in Children. Dig Dis. 2014, 32:114-119. Katza DA. The ‘Skinny” on Eosinophilic Esophagitis. Cleve Clin J Med. 2015, 82(2): 83-88. Lucendo AJ. Meta-Analysis-Based Guidance for Dietary Management in Eosinophilic Esophagitis. Curr Gastroenterol Rep. 2015, 17(37). Molina-Infante J et al. Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study. J Allergy Clin Immunol. 2018; 141(4): 1365-1372. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and the Association of Pediatric Gastroenterology and Nutrition Nurses. Eosinophilic Esophagitis. https://naspghan.org/professional-resources/medical-professional-resources/eosinophilic-esophagitis/

University of Wisconsin Health. Eosinophilic Esophagitis Nutrition Guidelines. http://www.uwhealth.org/healthfacts/nutrition/553.pdf Wolf WA et al Dietary Elimination Therapy is an Effective Option for Adults with Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2014, 12(8): 1272-1279. Zhan T et al. Model to determine the optimal dietary elimination strategy for treatment of eosinophilic esophagitis. Clin Gastroentrol Hepatol. 2018;16(11):1730-1737.

7-DAY MENU

Six Food Elimination Diet (SFED) Menu

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BREAKFAST Water with fresh lemon Mint tea (or other tea)

Steel cut oats,

ground flaxseed, coconut milk

1-2 slices gluten free toast w/ ½ avocado, sliced

tomato and sprouts

Coconut milk- based yogurt with fresh fruit

1-2 slices gluten

free toast w/ SPIKED

CILANTRO HUMMUS

POWER GREEN DRINK

OR Potato Rice Pancakes*

1-2 slices spelt

toast w/ sunflower

butter & apple butter or jam

LAZY LENTIL

SOUP (or other soup) w/

spelt tortilla

SNACK Water

• Fresh cut vegetables or wheat-free crackers with bean dip (hummus, black bean dip, lentil pate, etc.) • ½ avocado with EVOO and salt • Fresh or dried fruit • Sunflower and/or pumpkin seeds • Cup of dairy-free/wheat-free soup • Carrot cupcake* (gluten-free)

LUNCH Water Mint tea (or other tea)

1 cup black bean soup*

½ avocado,

tomato, cucumber and

greens in a wheat-free wrap

Large mixed

green salad w/ vegetables, legumes &

sliced cornmeal

crusted chicken* (or

grilled chicken)

1 cup COWGIRL

CHILI w/ Avocado butter*

(or sliced avocado)

OR Chickpea rotini with turkey and vegetables*

Sandwich on wheat-free

bread w/ sliced turkey, avocado,

tomato, thinly sliced red onion,

greens and Dijon

Large mixed

green salad w/ vegetables, legumes &

sliced chicken or Potato salad

Red quinoa

tabouli* topped w/

SPICED PARSLEY HUMMUS

Sandwich on wheat-free bread w/

Garlic roasted asparagus*, avocado &

Dijon

SNACK Water

SEE OPTIONS ABOVE

DINNER Water Mint tea (or other tea)

Cooked vegetables or

salad

½ cup cooked rice, quinoa or

wheat-free pasta; baked

potato (sweet or white)

SKILLET BROCCOLI

COWGIRL

CHILI

Black bean soup* w/ wheat-

free toast

Large green salad w/ SPIKED

CILANTRO HUMMUS

Cooked vegetables or

salad

½ cup cooked rice, quinoa or

wheat-free pasta; baked

potato (sweet or white)

LAZY LENTIL SOUP

Cucumber mint

salad*

Red quinoa tabouli*

Garlic roasted asparagus*

BUTTERNUT

SQUASH RISOTTO

Cucumber mint salad*

CURRIED

SWEET POTATO

MASH

SAVORY HERB

ROASTED

DIRTY LENTILS

OR

Roasted pork tenderloin with apples and sweet potatoes*

Cornmeal crusted chicken

CHICKEN

DESSERT Water

• Fresh berries • JACK’S BANANA ICE CREAM • Coconut or other fruit sorbet (e.g. Strawberry sorbet)* Baked pears*

*Recipes available below Recipes in CAPS are all available in What the Fork Are You Eating? (Tarcher/Penguin Random House, 2014)

RECIPES By Stefanie Sacks, MS, CNS, CDN

Cucumber Mint Salad Serves 4

Ingredients:

• 2 large seedless cucumbers, cut into 1/4" rounds • 2 tablespoons red onion, small dice • 1/4 cup mint, rough chop • 2 tablespoons extra virgin olive oil • 1/4 cup lemon juice, fresh squeezed • 1/2 teaspoon salt • Fresh ground pepper, to taste

Method:

1. Add all ingredients to a bowl and toss.

Garlic Roasted Asparagus

Serves 4 Ingredients:

• 1 bunch asparagus , trimmed • 1/2 tablespoon extra virgin olive oil • 1 lemon, juiced • 2 cloves garlic, coarsely chopped

Method:

1. Preheat oven to 350°. 2. Cut bottom end off asparagus (about 1 inch). Place stalks in small baking dish. 3. Add to baking dish olive oil, lemon juice and garlic, and toss, gently coating asparagus. 4. Bake, uncovered, for 15-20 minutes.

Black Bean Soup with Avocado Butter

Serves 4 Ingredients:

• 2 tablespoons extra virgin olive oil • 1 small yellow onion, small dice • 2 cloves garlic, rough chop • 2 carrots, 1/2 moons • 2 teaspoons ground cumin • 1 teaspoon dried oregano • 1 teaspoon ground coriander • 1/2 teaspoon chili powder • 1 pinch cayenne pepper • 2 15 ounce cans black beans, strained and rinsed • 4-5 cups water • 1 bay leaf • 1 teaspoon balsamic vinegar, or to taste • 1/2 bunch cilantro, rough chop • salt, to taste

Method:

1. In a large pot, heat oil on medium. Add onion, garlic and carrots; sauté for 5 minutes. Then add all spices and cook for another 3 minutes

2. Add rinsed beans and bay leaf to pot plus 4 cups of water (plus more if needed) and vinegar. Simmer for 30 minutes. Remove bay leaf.

3. Add cilantro and mix well. Let cool then purée soup in blender until creamy. Add salt to taste.

Avocado Butter

Serves 4 Ingredients:

• 2 avocados • 1 lemon juiced • 1 tablespoon water • 6 leaves mint • salt, to taste

Method:

1. Remove skin and pit from avocado. Place in food processor with lemon juice, water and mint. Puree until smooth. Add salt to taste. Serve atop Black Bean Soup.

Red Quinoa Tabouli Serves 4

Ingredients:

• 1 cup red quinoa • 1 1/2 cups water • 1/2 pint grape tomatoes, quartered • 1/2 seedless cucumber, small dice • 2 large scallions, thinly sliced • 2 cups flat leaf parsley, de-stemmed, loosely packed and rough chopped • 2 cloves garlic, minced • 1/4 cup extra virgin olive oil • 1/4 cup lemon juice, fresh squeezed • 1/2 teaspoon salt

Method:

1. Combine quinoa and water in medium pot. Cover and bring to a boil on medium; reduce to simmer and cook until water is absorbed and grain is fluffy (about 8-10 minutes).

2. Prep all vegetables and add to large bowl. When quinoa is finished, combine with vegetables and toss. Finish by adding dressing ingredients directly to same bowl and mixing well.

Cornmeal Crusted Chicken Cutlets Serves 4

Ingredients:

• 2 lbs. boneless chicken cutlets • 1 lemon, to clean chicken • salt, to clean chicken • 1 cup extra virgin olive oil • 1 cup yellow cornmeal, or rice flour • 2 tablespoons dried oregano • 2 tablespoons dried basil • 1 teaspoon salt, or more to taste at end • 1/2 cup grapeseed oil, for sautéing

Method:

1. Clean the chicken with salt and lemon juice, rinse under cold water and pat dry with a paper towel.

2. Place chicken in medium bowl and add olive oil to coat. Then combine cornmeal/flour

with herbs and salt on a large plate, mix well. 3. In large sauté pan, heat oil on medium. Dredge each piece of chicken in cornmeal/flour

mixture shaking off excess then place in hot pan cooking chicken 3-4 minutes per side until golden.

4. When done, place cutlets on paper towel covered plate to drain off excess oil. Salt to taste.

Carrot Cupcakes Serves 12

Ingredients:

Wet • 1 cup maple syrup • 1 cup carrots, grated • 1/4 cup coconut oil • 1/4 cup apple butter, or applesauce • 1 teaspoon pure vanilla extract • 1 cup coconut milk (Natural Value brand)

Dry • 2 cups gluten-free flour (Bob’s Red Mill brand) • 1 teaspoon cinnamon • 1/4 teaspoon nutmeg • 1/4 teaspoon ground cloves • 1 1/2 teaspoons baking soda • ½ teaspoon baking powder • ¼ teaspoon salt Topping • 1/4 cup pumpkin seeds

Method:

1. Pre-heat oven to 350˚ 2. Combine wet ingredients in large bowl; mix well. 3. Sift together all dry ingredients in separate bowl; then combine with wet and mix well. 4. Pour into muffin pan (using paper liners if necessary) to fill cup, top with pumpkin seeds

and bake for 20-25 minutes (be sure to rotate pan half-way through baking.

Recipes available at the American Academy of Allergy Asthma & Immunology

Potato rice pancakes Serves 4

Ingredients:

• 1-1/2 cup brown rice flour • 1/2 cup potato flakes • 1 T non-alum baking powder • 1 tsp. sea salt (optional) • 3 T vegetable oil • 2 cups water

Methods: 1. Combine dry ingredients. Set aside. 2. In separate bowl, combine liquid ingredients. Add to dry ingredients, mixing well. 3. Pour 1/4 cup portions of batter onto a hot, non-stick griddle or lightly oiled pan. Cook

until bottoms are lightly browned. Flip and continue cooking additional 1-2 minutes. 4. Serve with fruit topping.

Chickpea rotini with turkey and vegetables Serves 4

Ingredients:

• 1-1/2 cups hot cooked chickpea rotini pasta • 2 T oil • 1 cup carrots, sliced • 1/2 cup onion, chopped • 1 cup broccoli • 1 plum tomato, sliced • 1/2 lb. cooked turkey, cut into strips • 1/4 tsp. fennel seed

Methods:

1. Heat oil in large skillet over medium heat. 2. Sauté carrots, onion and fennel seed 2-3 minutes or until tender, stirring occasionally. 3. Add broccoli and tomato. Cook and stir 1-2 minutes or until broccoli is tender. 4. Stir in turkey and cook until thoroughly heated, about 2 minutes. 5. Combine pasta and turkey mixture.

Potato salad Serves 4-6

Ingredients:

• 4 boneless, skinless chicken breast halves • 1 lb red potatoes • 1 lb Yukon gold (or other "buttery") potatoes • 1 bundle asparagus spears (approximately 1 lb) • ½ cup olive oil • ⅓ cup balsamic vinegar (regular or white) • 2 T Dijon mustard • Salt to taste • Pepper to taste • 1 T dried dill (optional) • 1 T dried basil (optional)

Methods:

1. Cook the chicken in whatever manner you prefer. Cut cooked chicken into bite-sized pieces. Cool slightly.

2. While the chicken is cooking, wash the potatoes and cut into bite-sized pieces. Steam them for about 8 minutes (they will not be tender yet).

3. While the potatoes are steaming, prepare, wash and trim the asparagus. Cut asparagus spears into 2-inch pieces.

4. After the potatoes have cooked for 8 minutes, add the asparagus and continue to steam for another 7 minutes until the asparagus is tender (15 minutes total for the potatoes). Cool slightly.

5. While the asparagus is cooking, prepare the dressing. Whisk together the olive oil, balsamic vinegar, Dijon mustard, salt, pepper, and either the dill or basil.

6. In a large bowl, combine the chicken, potatoes, asparagus and dressing. Toss to coat. 7. Add additional dill or basil if you would like more flavor. Can be served warm or cold.

Roasted pork tenderloin with apples and sweet potatoes

Serves 4

Ingredients:

• 1 tsp. salt • 1/2 tsp. ground cinnamon • 1/2 tsp. ground cardamom • 1/4 tsp. pepper • 3-1/2 cups sweet potato, peeled and cubed • 4 tsp. olive oil, divided • 2 12 oz. pork tenderloins • 3 large Granny Smith apples, peeled and cut into wedges

Methods:

1. Preheat oven to 500° F. 2. Coat 15x10-inch jelly roll pan with cooking spray. Set aside. 3. In small bowl, combine salt, cinnamon, cardamom and pepper. Set aside. 4. In large bowl, combine sweet potato, 1 tsp. spice mixture, and 3 tsp. oil; toss well. Set

aside. 5. Trim fat from pork and rub remaining spice mixture over meat. 6. Drizzle remaining oil over pork. 7. In a single layer in pan, arrange sweet potatoes. Bake 10 minutes. 8. Add apples and pork; bake 10 minutes. 9. Turn sweet potatoes, apples, and pork and bake an additional 10 minutes. Turn once

more and bake 10 minutes.

Strawberry sorbet Serves 6

Ingredients:

• 6 cups of sliced strawberries • ⅔ cups sugar or honey to taste • ¼ cup lemon juice • ½ cup raspberries

Methods:

1. Mix all ingredients together in a blender or food processor and puree. 2. Place mixture in ice cream maker and freeze according to manufacturer's instructions. 3. Mixture can be strained through a fine sieve for a smoother, seed-free texture. 4. Lemon juice can be omitted or replaced with another souring agent such as amchoor

powder (green mango) or ground pomegranate seeds.

Baked pears Serves 4

Ingredients:

• ½ cup rice syrup (may substitute corn or maple syrup for rice syrup) • ½ cup water • 2 Tbsp lemon juice or vitamin C crystals • 4 pears

Methods:

1. In a small bowl, combine water, rice syrup and lemon juice or vitamin C crystals. 2. Peel pears and arrange them, whole, in an oven-proof dish. 3. Pour syrup over fruit and bake at 350° F for 40 minutes, or until tender.

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