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Jul 3, 2019 · A Nurse's Perspective of Starting SFED in Eosinophilic Esophagitis


Two of the esophageal nurses at Mayo Clinic Rochester undertook the six food elimination diet. They dove in and followed complete elimination, followed by each food re-introduction. While they didn’t have to sample their esophagus at each step, they did get a firsthand look at what the diet is all about and its challenges and rewards. Here’s what Kari, RN and Sarah, RN have to say about their experiences:

  1. How did you go about starting the SFED?
    • Kari: We started the diet on a Tuesday. Unfortunately, I wasn’t able to get to the store for groceries until Thursday, so the first two days were exceptionally challenging. Upon looking at what was in my pantry, I realized there wasn’t anything I could eat!
    • Sarah: I took on an “adventure” perspective. I wanted to answer the question, “How can I help patients get started to increase success and lower stress?” I also quickly realized that I’d need to find appropriate substitutions to my staple foods.
  2. What was grocery shopping like? Did you try any new foods?
    • Kari: I spent a lot of time at the grocery store reading labels. Finding foods was very challenging and I quickly learned that some of the foods are hidden. Soy and wheat are in a lot of things! Once I found a few things I knew were SFED-safe, I found myself eating the same things over and over again.
    • Sarah: My goal was to find some foods to rely on, but to expand with a new food every couple of days to broaden my horizon. During that first shopping experience, I realized the importance of planning ahead. You need to have a well thought-out grocery list. Chocolate coconut milk, although difficult to find, was a major treat!
  3. Did you go out to restaurants? Was it easy or difficult to find something on the menu that was SFED-friendly?
    • Kari: It was very difficult. I’d say next to impossible, because you don’t really know what’s hidden in the food itself, or how it’s prepared. My first experience eating out I had a grilled chicken breast with no bun, a baked potato with salsa (no butter) and bacon bits, and corn.
    • Sarah: The first weekend after we decided this I was on a weekend trip with lots of eating out. That was very challenging and I have to admit I probably cross-contaminated. Like Kari said, you don’t really know exactly what’s in the food or exactly how it’s being prepared. The people I was with kept remembering this too, and would make comments such as “Oh, that’s right, you can’t eat that.” That stinks to hear all the time. I also noticed the workers and servers were getting irritated with me when I asked all kinds of questions, trying to be compliant.
  4. Let’s talk about food re-introduction. Things got easier then, right?
    • Kari: Not necessarily. The first few foods tend to “go” with other foods that were still out. For example, when fish was added I thought about having a tuna sandwich, however mayo (eggs) and toast (wheat) were still out. As the foods were re-introduced, it did get easier again.
    • Sarah: Agree with Kari on this one. At first, I didn’t really care if I had any fish, but I tried to include it at least 3 times per week like patients need to. However, I just kept thinking about all the other foods I still couldn’t have! In the midst of adding foods, eating out was still challenging since not everything was back in yet.
  5. What would be your most helpful tip for someone just starting out?
    • Kari: Make a plan before you go shopping. I am not one to preplan my meals very well and this diet makes that necessary and I found I was very hungry that first week and shopping experience. Plan on making as many of your meals and snacks as possible so you know exactly what is in your food. Use available tools, like an app on your phone. And prepare yourself for the emotional changes on the diet.
    • Sarah: We had the luxury of knowing that we will not have to eliminate anything when this is done. This is a long process and much more intense for patients. I identified I may have a dysfunctional relationship with food, so be aware of possible addiction feelings and emotions towards that! Use your resources, and remember that your support team will get used to your new eating habits too.

Have you already gone through SFED, or are thinking about it as a treatment option? What are your concerns? What helped you on that first shopping experience? Share your best tip or ask a question for others below!

Jun 26, 2019 · Food Labels: What to look for in Eosinophilic Esophagitis

The Food Allergen Labeling and Consumer Protection Act (FALCPA) requires that food manufacturers identify common allergens in plain English. These common allergens, which represent about 90% of all food allergies, include milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, and soy. If any one of these foods is used as an ingredient, it must be clearly indicated on the nutrition label. It can be indicated in an allergy statement at the bottom of the ingredient list or within the ingredient list, as shown in the examples below. If the label does not indicate that milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, or soy, the food is considered safe to eat on the six food elimination diet.

Meat, poultry, fish and egg products are not required by law to be included in an allergen statement. If you do not see an allergen statement on these foods, do not eat the food until you make sure it does not contain milk, wheat, soy, eggs, nuts/peanuts, or fish/shellfish.

Allergen advisory statements, such as “made in a facility with” or “processed on shared equipment with” are not reliable indicators of the presence of an allergen. Manufacturers may choose not to include these statements even if their products are processed using shared equipment or facilities. All products are required to be made using Good Manufacturing Practices, which are regulations from the Food and Drug Administration (FDA) to prevent cross-contamination.

Remember, ingredients in a product can change, so be sure to read the ingredient lists regularly.

Food label


*Sourced from Eosinphilic Esophagitis education booklet available at Mayo Clinic Patient Education

Jun 11, 2019 · Meet the SFED Food: Wheat in Eosinophilic Esophagitis

WheatWheat is a grain used to make many common foods, such as breads, cakes, cereal, crackers, and pasta. However, it can also be found in less obvious sources, such as beer, soy sauce, salad dressing, soups, and play dough. A wheat allergy occurs when an individual’s immune system has an unusual reaction to the protein found in wheat.

Where Is It Found?

Wheat can be called many names – here are a few to watch out for:

  • Flours made from wheat (including all-purpose, bread, cake, enriched, wheat)
  • Couscous
  • Spelt
  • Wheat bran
  • Wheat germ
  • Farro
  • Semolina
  • Bulgur
  • Graham
  • Farina

How Can You Substitute It?

Does your baking recipe call for wheat flour? Try substituting flour made from rice, potato starch or corn. Many grocery stores sell gluten free all-purpose flours too. A combination of wheat free flours usually works best for baking. Wheat free baking generally results in a more crumbly texture and a shorter rise. Here’s a recipe for gluten free flour blend:

  • 1 ½ cups brown rice flour
  • 1 ½ cups potato starch
  • 1 cup tapioca flour/starch
  • Mix all ingredients together. Store in an air-tight container. Makes 4 cups.

Does your recipe call for wheat flour as a thickening agent? Try using cornstarch, tapioca or arrowroot flour or a gluten free flour.

Does your recipe call for breadcrumbs for a coating? Try using cornmeal, crushed potato or corn chips, crushed wheat-free crackers, crushed rice or corn cereal, or ground seeds, such sesame or pumpkin.

Making a sandwich or using a tortilla? Try using a lettuce leaf, corn tortilla or a slice of gluten free bread – if you have other allergies, be sure they are also free from other allergens.

Try wheat free grains, such as gluten free oats, millet, rice, quinoa, amaranth, pure buckwheat or cornmeal.

Is Gluten Free The Same As Wheat Free?

Gluten free foods are wheat free, but some gluten free foods contain soy, dairy or other allergens. Be sure to read the ingredient list if you have other allergies.

 Here’s a recipe for a cake that uses gluten free flour, vinegar and oil:

Wacky Cake

1½ cups gluten free all-purpose baking flour

1 cup sugar

3 Tablespoons unsweetened cocoa powder

1 teaspoon baking soda

1 teaspoon salt

1 teaspoon vanilla

1 teaspoon vinegar

¼ cup plus 1 Tablespoon oil

1 cup cold water

Preheat oven to 350 degrees.  In a large bowl, mix flour, sugar, cocoa, baking soda and salt.

Make three wells in the flour mixture.

In one well put the vanilla; in another well put the vinegar and in the third well add the oil.

Pour the cold water over the mixture and stir until moistened.

Pour into an 8×8 inch pan.  Bake 25-30 minutes (or until it springs back when lightly touched).

Sourced from


Do you have a favorite wheat-free recipe or substitution?

Jun 5, 2019 · Meet the SFED Food: Milk in Eosinophilic Esophagitis

You’ve decided to pursue the six food elimination diet and are at the beginning of your journey.

You’ve always been a huge milk drinker and now you have to give up dairy. How will you survive? Where will you get your calcium from? Some of your friends have lactose intolerance, can I still eat lactose free foods?

Read on for answers and solutions.


Next to wheat, milk is the most common cause of food allergy in adults and is the most common allergy among children. People with a milk allergy must avoid milk in any form, including cheese, yogurt, butter, cream, pudding and others. Milk is also added to other foods in the form of whey, casein, lactalbumin and other milk derived ingredients. Milk derivatives can be found in some unexpected places such as hot dogs, margarine and even nondairy products, so it is important to read labels on all foods. A food can be labeled “nondairy” even if it has casein in it. The ingredient statement on nondairy products will list casein and the word milk if it is an ingredient. Learn to read food labels for milk ingredients.


Milk provides a good source of many nutrients essential for general health and especially bone health. These nutrients include protein, calcium, vitamin D, vitamin A, vitamin B 12, riboflavin and phosphorus. When you eliminate milk, you may lose these essential nutrients from your diet and will need to choose foods to replace these lost nutrients. Meat, poultry, eggs, fish, nuts and legumes can easily provide protein. However, dairy foods are our richest source of calcium and vitamin D. Most adults need 1000 mg calcium per day and 600 units of vitamin D . You can get calcium from nondairy foods but you would have to eat a lot more, as shown in the below chart. If you drink nondairy milk, make sure it has been fortified with calcium and vitamin D. Most nondairy milks do not contain these nutrients naturally. Also review the nutrition information on the package to check the amount of protein. Soy milk and pea milk are generally the closest in protein content to cow’s milk. Most nondairy milks contain very little protein. If you are not able to get your quota of calcium from your diet, there is nothing wrong with taking a calcium supplement, as long as you choose one that is allergen free.

Dairy Food Calcium (mg)
Milk, 8 oz 300
Yogurt, 8 oz 300
Cheese, 1 oz 200
Nondairy Foods
Most nondairy milks, 8oz 300+
Orange juice, calcium fortified, 8 oz 300
Fortified cereals

(such as Cheerios, Rice Chex),   1 cup



Leafy green vegetables (collards, spinach), 1/2 cup cooked 120
Kale, 1/2 cup cooked 50
Tofu, 1/2 cup 150
Soybeans, 1/2 cup cooked 90
Other beans (pinto, navy), 1/2 cup cooked 40-60


Vitamin D is more difficult to get unless you drink milk. It may be better to take a supplement. A multivitamin will provide the daily requirement of vitamin D.

Milk Substitution

There are many milk alternatives made of seeds, grains and other foods. These include rice, hemp, flax, coconut, oat, pea and others. If you are not allergic to soy or nuts, you can also use soy, almond, cashew or macadamia nut milks. Most of these milks can be substituted 1 for 1 in recipes. Many are available in original or plain, flavored, sweetened and unsweetened. The unflavored varieties work best in recipes.

You can make your own buttermilk by adding a tablespoon of vinegar to 8 ounces of nondairy milk. Substitutes for cream include canned coconut milk or nondairy creamer. Again, always check the ingredients.

In cooking, you can substitute nondairy margarine or oil for butter. The nondairy margarine also works as a tasty spread.

Nondairy yogurt, sour cream and cream cheese products are available in many grocery stores. Milk free ice creams and other products are also available. Be sure to check ingredient statements to make sure they contain no milk ingredients. Cheeses made from soy are available in chunks or shreds for recipes that call for cheese.

Depending upon the function of the dairy product in your own recipe, sometimes you can create a safe version of the original recipe, but sometimes you’re better off finding a different recipe altogether.

Have any tips or tricks for substituting dairy?

May 29, 2019 · Cross Contact During SFED in Eosinophilic Esophagitis

ChixVeggieSauceCross contact happens when one food comes into contact with another food. As a result, each food then contains small amounts of the other food. These amounts are so small that they usually cannot be seen. However, even this small amount can affect people with food allergies. This is also known as cross contamination. Many people find cross contact to be one of the most difficult parts of the diet to manage.

Where does cross contact occur?

Cross contact can occur anywhere foods come together. This can happen in fields, factories, restaurants or even in your own home. Think of removing the bun and eating just the hamburger patty or eating a salad after removing the croutons. While the main culprit has been removed, leftover debris is still present on that patty or salad. Other sources of cross contact include:

At home
  • Toaster (even a crumb can affect some people with allergies)
  • Toaster oven
  • Grill
  • Deep fryer
  • Waffle iron
  • Cutting board
  • Strainer
  • Colander
  • Counter tops
  • Anything made of porous material such as wooden spoons or a rolling pin
  • Shared condiments such as butter/margarine, peanut butter, mayonnaise, jelly/jam or anything else people dip a knife or spoon into
  • Shared dish rags or sponges
  • Other places food particles may hide including silverware trays, cupboards, shelves and even knife blocks
In restaurants
  • Grills that have been used for breaded meats or pancakes
  • Deep fryer used for batter fried foods
  • Serving spoons at a buffet table or salad bar
  • Using the same water for regular pasta and then wheat free pasta
  • Airborne allergens in bakeries or pizzerias, or baking pans used for regular pizza
In food processing or production
  • In fields, where wheat free grains are grown in fields next to wheat containing grains
  • In shipping, where allergen free foods are shipped in the same trucks or train cars as those containing allergens
  • In factories, where allergen free foods may be stored or made on the same equipment used for allergen containing foods

What are some steps you can take to protect yourself from cross contact?

  • Wash pots, pans, dishes and utensils thoroughly with soapy water or in a dish washer after each use.
  • Use separate cutting boards, strainers, colanders, toasters and waffle irons. Some people like to choose a different color to identify the allergen free kitchen tools.
  • Prepare the allergy safe foods first.
  • Keep the allergen free foods covered and away from other foods that may contain allergens.
  • Thoroughly wash counters and tables with soap and water.
  • Do not share food, drinks or utensils.
  • Have separate containers of butter, mayonnaise, peanut butter and other spreadable condiments. Label the allergen free ones.
  • Store allergen free items on the top shelf of your pantry and refrigerator to prevent crumbs from falling into allergen free foods. Have a dedicated shelf for foods.
  • Read labels to assure products are free of allergens.


How will you assure your foods are safe from cross contact?

May 22, 2019 · Using the Cytosponge to Test for Eosinophilia in Eosinophilic Esophagitis


The upper endoscopy is the gold standard way for doctors to assess your esophagus and take biopsies, or tiny pieces of tissue, to test for eosinophils in your esophagus.

Dr. Rebecca Fitzgerlad of Cambridge University has developed the Cytosponge, a capsule with a string attached, as an alternative way to retrieve esophageal tissue. This tissue can be tested in the same way that biopsies are tested in pathology.

Dr. David Katzka of Mayo Clinic in Rochester is using the Cytosponge to monitor Eosinophilic Esophagitis. Watch the video to learn more about this exciting new testing device.


The team anticipates clinical use in the future. To find out more about the Cytosponge and studies available, email or call Mayo Clinic Rochester at (507) 284-2141.

May 15, 2019 · Stretching The Esophagus During EGD in Eosinophilic Esophagitis


A common risk in EoE is narrowing and scarring of the esophagus. This causes food to go down slowly and stick. Even with medication treatment, the esophagus will remain narrow and you may not feel the medication benefits. Dilation, or stretching, is done while you are having an upper endoscopy. While it is disrupting the mucosa, doctors carefully examine how receptive your esophagus is to dilation and only stretch a little bit each time. Watch the video below as Dr. Jeff Alexander at Mayo Clinic Rochester talks about dilation and the risk and benefit for eosinophilic esophagitis.


May 13, 2019 · Narrowing in EoE: Available Testing in Eosinophilic Esophagitis

Have you had an esophagram done? Is it on your patient appointment guide? Are you wondering what that is? Watch below as Dr. Jeff Alexander at Mayo Clinic Rochester explains narrowing of the esophagus in eosinophilic esophagitis, how the esophagram imaging test is performed, and how it helps doctors make recommendations for your treatment and upper endoscopy dilation, or stretching. Dr. Alexander will also explain another diagnostic way to measure the diameter of the esophagus, EndoFLIP.