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Rakel: Integrative Medicine, 2nd ed.
Copyright © 2007 Saunders, An Imprint of Elsevier
Part III – Tools for Your Practice
Section 1 – Lifestyle
chapter 86 – Adverse Food Reactions and the Elimination Diet
J. Adam Rindfleisch, MD, MPhil
Adverse Food Reactions: What Are They? 942
Pathophysiology 942
Diagnosing Adverse Food Reactions 943
The Elimination Diet for Treating Various Disorders 943
Attention Deficit–Hyperactivity Disorder 943
Atopic Dermatitis 944
Irritable Bowel Syndrome 945
Migraine Headache 945
Chronic Serous Otitis Media 945
Rheumatoid Arthritis 946
Prescribing an Elimination Diet 946
What Is an Elimination Diet? 946
1: The Planning Phase 946
2: The Avoidance Phase 946
3: The Challenge Phase 947
4: Creating a Long-Term Diet Plan 948
Risks of Elimination Diets 948
Detecting and eliminating specific antagonistic foods, and designing a
nutritionally sound diet to ensure the optimum health of the food-sensitive
person, is the ultimate aim in food sensitivity management. This process is often
tedious and time consuming, and requires tremendous knowledge, skill,
commitment, and dedication. … However, when a person who has been
chronically sick suddenly feels well for the first time in many years, as so often
happens, the rewards for both practitioner and client more than justify the time
and effort of the endeavor.
J. V. Joneja, Dietary Management of Food Allergy and Intolerance
[1]
In 1997, something remarkable happened in the Central Alternative High School in
Appleton, Wisconsin. The school, created to accommodate 100 students with behavior and
discipline problems, changed its cafeteria menu. Through the school's Wellness and
Nutrition Program and with the help of a private organization called Natural Ovens, fast
foods were replaced with salads. White bread products were replaced with whole grain
foods. Meat dishes were prepared with the use of “old-fashioned recipes,” and fresh fruits
were added to the menu. Vending machines disappeared overnight, and during school
hours, students were not allowed access to soft drinks, candy, chips or chemically processed
food items.
In less than a year parents, teachers, students, and school administrators started to notice a
change, and most attributed it to the change in the quality of the students' food. Attendance
at the school improved. Grades got better. There were fewer fights. The incidence of drug
and weapon use decreased, and teachers found themselves able to spend more time teaching
rather than maintaining discipline. The change was so dramatic that the entire Appleton
School District, which enrolls 15,000 students, changed what all of its cafeterias serve.
Other school districts have been encouraged to do the same.
[2] [3]
Eliminating certain foods and emphasizing the use of others has been an emphasis of
Ayurvedic healing in India for centuries. Just as caregivers must consider the potential
adverse effects of a patient's drugs and supplements, they must also be attuned to the
potential adverse effects of the foods their patients eat. Pesticide contamination, the use of
growth hormones and antibiotics in meat production, genetic engineering of food sources,
and the health risks associated with fast and processed foods are all topics of concern that
can arise in an integrative medicine visit.
[4]
For many disorders, identifying adverse food reactions and recommending elimination diets
can be quite useful. This chapter discusses the state of the research on the elimination diet
as a clinical tool for a number of conditions. Tips for prescribing elimination diets, pitfalls
to avoid in their use, and resources for further information are also provided. A Patient
Handout on elimination diets appears at the end of the chapter.
The clinician making any dietary recommendations for patients should consider
suggesting the following:
•
Eat organic foods when possible. (Remember that doing so can be difficult for
patients living in certain geographical areas or with limited financial resources.)
•
Cook your own food when possible.
•
Minimize intake of fast food.
•
Thoroughly wash foods that have been sprayed with pesticides or herbicides.
•
Use caution in eating meats from animals treated with hormones or antibiotics.
Consider a move toward a predominantly vegetable-based diet.
•
A good rule of thumb is to avoid foods with more than two lines of ingredients
listed on the packaging.
Adverse Food Reactions: What Are They?
Adverse reactions to foods are divided into two main categories, food allergy and food
intolerance. Food allergy involves an immune-meditated reaction, usually to a glycoprotein,
found in a given food. Food intolerance, in contrast, is defined as any “adverse physiologic
response” to a food product. An intolerance may be due to the presence of a toxic
contaminant (e.g., in food poisoning) or to pharmacologic properties of substances normally
found in a food (e.g., headaches caused by tyramine in cheese and wine). Some forms of
food intolerance are classified as specific disorders (e.g., lactose intolerance), but others
may be more idiosyncratic in nature. Table 86-1 lists key differences between food allergy
and food intolerance.
[5]
TABLE 86-1 -- Adverse Food Reactions: Food Allergy versus Food Intolerance
FOOD ALLERGY
FOOD INTOLERANCE
Prevalence increasing, now 3.5% to
4% of Americans
Prevalence uncertain, but perceived intolerance may be
as high as 20%
Immune-mediated, mainly via IgE
Cause unclear, but may be influenced by IgG, hormonal
changes, decreased intestinal permeability, alterations in
levels of inflammatory mediators, or (most likely) a
combination of these and other factors
Symptoms arise in minutes to hours
Symptoms arise in hours to days
[5]
Typically manifests as rash,
May manifest as any number of symptoms or disorders.
anaphylaxis, or specific disorder, such More research is needed to clarify this issue.
as protein–induced enteropathy and
dietary protein–induced proctitis
Ig, immunoglobulin.
[6]
A number of disorders are widely accepted as being directly influenced by food. Examples
include celiac disease, lactose intolerance, gout, cholelithiasis, nephrolithiasis, and
gastroesophageal reflux disease. However, for other disorders, the relationship between
foods eaten and symptoms is less clear.
The existence of a relationship between food intolerance and various disease processes
continues to be debated. An elimination diet can serve as a simple and, if done properly,
safe way to determine whether or not foods may be affecting a person's health.
Pathophysiology
Although it is known that food allergies are mediated by the presentation of antigens via
immunoglobulin E (IgE) to B lymphocytes, the origin of food intolerance is less clear.
Several hypotheses for how food intolerance occurs have been proposed, but it may be that
multiple factors play a role.
The epithelial cells of the gastrointestinal tract have been found to function as
nonprofessional antigen-presenting cells. The gut is constantly sampling various potential
antigens, ultimately allowing only 2% of them to move into the bloodstream. The epithelial
cells, gut dendritic cells, and at least five different T-cell types help regulate intestinal
immunity. One of the T cells' main functions is to allow tolerance to develop; that is, the
body must be able to minimize allergic reactions to the foreign antigens commonly
consumed in foods. In some individuals, this process seems to break down, and certain
foods begin to elicit symptoms.
[5]
[5]
Greater intestinal permeability, or “leaky gut,” has been proposed as one means by which
antigens that are typically unable to cross through the intestinal tract into the bloodstream
become capable of doing so. Molecules that would normally be too large to pass from the
gut into the bloodstream are suddenly able to move in, eliciting any number of negative
physiologic effects. Permeability seems to be increased by a number of factors, including
inflammation, exposure to medications (e.g., nonsteroidal anti-inflammatory drugs), shifts
in intestinal microflora, and the presence of various disease states, such as celiac disease
and ulcerative colitis. Leaky gut is known to be increased with radiation therapy, in
patients with intermittent claudication, and in people with multiple sclerosis. Its presence
has been correlated with higher risk of cirrhosis in people with chronic alcoholism.
[7]
[8]
[9]
[10]
[11]
[12]
Diagnosing Adverse Food Reactions
For food allergies, a number of tests can be considered, although they may not be readily
performed in a primary care practice. Ideally, a double-blind, placebo-controlled food
challenge (DBPCFC) is the gold standard for establishing that a food allergy exists.
However, this challenge may require intravenous access, and the food products and
placebos can be difficult to prepare and/or mask. Only 30% of positive open food challenge
results correlate with positive blinded challenge results, suggesting that adverse food
reactions are strongly influenced by mind-body interactions. Radioallergosorbent testing
(RAST) and, possibly, skin-prick testing are helpful to assess for the presence of food
allergies, but they will not rule out food intolerance. Interestingly, one trial found that diet
history and skin-prick testing seemed to correlate well in predicting food allergies, but skinprick testing, antibody measurements, and DBPCFC did not correlate well at all with one
another.
[13]
[14]
[15]
[16]
Laboratory testing, although quite useful for food allergy, remains to be validated in clinical
trials for food intolerance. Thus far, the IgG4 levels, applied kinesiology, and other methods
have not been proven valid. Patch testing, although potentially useful, is not yet
[17]
appropriately standardized. The ALCAT test (www.alcat.com ), which is used by some
clinicians to test for intolerance to food additives, is also controversial.
[5]
[18]
Although formal allergy testing may be considered for suspected food allergy, elimination
diet remains both the diagnostic method and the treatment method of choice for suspected
food intolerance. Consider a formal referral to an allergist if an allergy is suspected,
particularly in a child or a person with a history of a rapid and severe allergic reaction to a
food product.
The Elimination Diet for Treating Various Disorders
Table 86-2 lists a number of disorders for which treatment using elimination diets has been
suggested. The elimination diet has been evaluated mostly for use in treating attention
deficit–hyperactivity disorder (ADHD), atopic dermatitis, irritable bowel disease, migraine
headache, otitis media, and rheumatoid arthritis; the evidence for its use in these disorders is
reviewed in detail. Table 86-3 lists foods that should be considered for removal in an
elimination diet to treat each of the disorders discussed here.
TABLE 86-2 -- Conditions for Which Elimination Diets Might Be Used
Cardiovascular
Palpitations
Tachycardia
Dermatologic
[1] [18] [19]ii[*]
Angioedema †
Atopic dermatitis (see text) †
Contact dermatitis
Dermatitis herpetiformis
Pruritus †
Urticaria †
[20]
Gastrointestinal
Bloating/belching
Celiac disease †
Cholecystitis/cholelithiasis †
Chronic diarrhea
Colic
Constipation in childhood
Cyclic vomiting syndrome †
Encopresis
Gastroesophageal reflux
Irritable bowel syndrome (see text) †
Inflammatory bowel disease
†
Nausea/vomiting/diarrhea
Recurrent abdominal pain in children (with confirmed food
allergy)
[21]
[22]
[23]
[24]
[25]
[26] [27] [28] [29]
[30]
Genitourinary
Enuresis †
Frequency
[31]
Interstitial cystitis
Vulvodynia
Neurological/psychological Attention deficit–hyperactivity disorder (see text) †
Infantile autism
†
Medication-resistant depression
Migraine (see text) †
Other headache
Seizures (via ketogenic diets) †
[32] [33] [34]
[35]
[36]
Respiratory/otolaryngologic Aphthous ulcers (recurrent)37
Asthma
†
Chronic congestion/rhinitis †
Chronic serous otitis † (see text)
Conjunctivitis
Laryngeal edema/hoarseness
Rheumatologic
Chronic fatigue
Rheumatoid arthritis (see text) †
Systemic lupus erythematosus
Vasculitis
[38] [39] [40]
[41]
[42] [43]
[44]
Miscellaneous
Listlessness/poor concentration
Irritability
Chilliness/low-grade fever
Dizziness
Excess sweating
Pallor
*
Individual studies cited for specific disorder when available.
†
Indicates that at least level B evidence (SORT criteria) exists for treatment of this condition with use of an elimination diet.
TABLE 86-3 -- Foods to Eliminate to Treat Specific Disorders
CONDITION
FOODS TO ELIMINATE
[*]
Attention deficit–
hyperactivity
disorder
Apples, artificial colors, aspartame (e.g., NutraSweet), BHA (butylated
hydroxyanisole),
BHT (butylated hydroxytoluene) (in packaged cereals), benzoates (chewing
gum, margarine, pickles, prunes, tea, raspberries, cinnamon, anise, nutmeg),
caffeine, corn, dairy products, nitrates and nitrites (preserved meats like
bacon, frankfurters, pepperoni), oranges, propyl gallate, sulfites (dried
fruits, mushrooms, potatoes, baked goods, canned fish, pickles, relishes),
peanuts, tomatoes.
Atopic dermatitis
Children: Dairy, eggs, soy, wheat.
Adults: Pollen-related foods (fruit, nuts, vegetables).
Other considerations would be artificial colors, benzoates, berries, citrus,
currants, fish, legumes, sulfites, tomatoes, and, occasionally, beef, chicken,
[1]
[46]
[1]
CONDITION
FOODS TO ELIMINATE
pork, and tomato.
Irritable bowel
syndrome (IBS)
Migraine
[1] [47]
[18] [48]
Dairy, eggs, wheat.
Some diets become quite elaborate, focusing on which starches should and
should not be consumed. See Joneja1 for a comprehensive IBS diet.
Beef, chocolate, coffee, corn, eggs, histamine (fish, cheese, wine, beer),
monosodium glutamate (mushrooms, kelp, scallops, preserved meats,
Chinese food), nitrates (processed meats), oranges, sugar, tea, tyramine
(aged cheeses, some red wines), yeast.
Serous otitis
media
See the level 2 diet in the patient handout.
Consider removing dairy foods.
Rheumatoid
arthritis
Consider the few-foods diet given in the patient handout.
Corn, dairy, and nightshade vegetables (bell peppers, eggplant, potatoes,
tomatoes) are worth considering.
[49]
[50] [51] [52]
*
Other foods may also be implicated.
Attention Deficit– Hyperactivity Disorder
The role of food intolerance as a contributor to hyperactivity in children has been debated
for nearly 90 years. In 1975, Benjamin Feingold created a diet for children with learning
and behavioral disorders, but the diet fell out of favor when his impressive results were not
found to be reproducible. It is generally held that children affected by food intolerance
show signs of irritability and restlessness, among other symptoms. Several food additives
are known to have direct physiologic effects on the central nervous system, such as the dye
tartrazine (yellow dye #5), benzoates, glutamate (a flavor enhancer), and benzoates (used as
preservatives). Children may be particularly vulnerable to the effects of these chemicals.
[45]
[53]
[1]
A number of studies point to a relationship between consumption of certain foods and
behavioral problems in children with ADHD, as follows:
•
In 2002, Pelsser and colleagues found that 25 of 40 Danish children (mostly boys) put
on a few-foods diet received significantly improved behavior ratings from their parents
and/or their teachers. Of note, 9 children withdrew from the trial. Compliance is
commonly a challenge when more stringent elimination diets are used.
•
A 1994 study by Boris and Mandel reported that 19 of 26 children showed favorable
response to elimination diets. It was found that in 16 of the 19 children with favorable
responses, the results could be confirmed with a DBPCFC.
•
Carter and coworkers reported in 1993 that 58 of 78 children with ADHD improved in
an open trial. A few-foods diet was used, and the choice of foods to eliminate was based
largely on parents' suspicions. In this study, DBPCFCs confirmed intolerances in 19 of
the respondents.
[54]
[55]
[56]
Several reasons have been given for why children with ADHD show response to special
diets, in addition to the hypothesis that symptoms are directly associated with eating certain
foods. Behavior may also change in part because of the extra attention children receive from
their parents during a special diet and in part through the improvement in overall nutritional
status that can result from using such diets.
[1]
The elimination diet listed in Table 86-3 for a child with ADHD could also potentially work
for adults with similar symptoms.
Atopic Dermatitis
A 2002 review of complementary medicine treatments for skin disease noted that the diets
of both the mother and the infant seem to influence the development of atopic dermatitis in
young children, although how much of this is due to food allergy rather than intolerance
remains unclear. Dietary restrictions for the mother during pregnancy, then later for the
infant, resulted in a 16% rate of atopic dermatitis in the treatment group, compared with a
27% rate of AD in the control group. No changes were noted in rates of infant asthma,
urticaria, and rhinitis.
[57]
[58]
Sampson and colleagues evaluated more than 400 patients with atopic dermatitis using
DBPCFCs. Egg, milk, peanut, soy, and wheat accounted for 87% of the positive challenge
results. Seventy-five percent of the adverse responses involved the skin. A 22% to 50%
noncompliance rate was noted in this study.
[59]
[57]
A Korean study divided 524 patients with atopic dermatitis into four groups. One group
was treated with interferon-gamma, one group with an elimination diet, and one group with
both interventions; the fourth group was the control group. Comparison of the three
treatment groups with the control group revealed that clinical severity of skin symptoms
was significantly lower in the elimination diet–only group, by more than 58%. Combining
an elimination diet with interferon-gamma was more effective than interferon-gamma alone.
A food challenge demonstrated adverse reactions to foods in 78% of the subjects.
[60]
A 1991 study evaluated 91 children with eczema who initially were given an elimination
diet and subsequently underwent random-order, double-blind food challenges. Clinical
improvement was observed in 49 of the 66 patients, and the researchers noted that
symptoms worsened substantially after cows' milk and tomato were reintroduced. There
was a correlation between how long foods had been avoided and the likelihood they would
elicit symptoms. Verifying results with subsequent food challenges was difficult, because
many of the children refused to eat the foods they believed would bring back their
symptoms.
[61]
In 1987, Veien and colleagues carried out a food challenge using various food additives in
101 people with eczema. Thirty-seven people reacted to one or more additives without
reacting to placebo, and 16 reacted to the placebo or to both the placebo and the additives.
Again, the importance of mind-body interactions in influencing symptoms should be noted.
Reactions were reproducible in only one third of the subjects when repeat challenges were
performed later. Given this diagnostic dilemma, the researchers concluded, “If intolerance
[26]
to food additives is suspected, an elimination diet seems warranted, regardless of whether
the patient reacts to oral challenge with food additives.”
[26]
Table 86-3 lists foods thought to be most likely to trigger flares of atopic dermatitis.
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) affects 10% to 15% of the world's population, and surveys
show that 60% of patients with IBS believe they have some sort of dietary “allergy” that
affects their symptoms. Given that 50% of patients report that their IBS symptoms most
often arise postprandially, it is understandable why a food intolerance would be thought
likely. At times, an elimination diet may be the only way to verify these suspicions. A
“cephalic” response to food—a rise in motility rate simply with the sight or smell of food—
is noted in many patients with IBS. This observation lends complexity to making a
diagnosis of food intolerance in this patient population.
[47]
[62]
[47]
It has been noted that many patients with IBS exhibit “cephalic” responses to food—that
is, their motility rates rise when they simply see or smell food, let alone eat it.
In a 1982 systematic review, Alun-Jones and colleagues concluded that strict elimination
diets could help at least one in three individuals with diarrhea-predominant IBS. Niec and
associates reviewed seven studies of elimination diets for IBS and found the response rate
to range from 15% to 71%, with improvement being most likely for subjects with diarrheapredominant disease. DBPCFCs identified problem foods in only 6% to 58% of the cases in
these studies. The reviewers noted that the relationship between adverse food reactions and
IBS was unclear, commenting that there were a number of methodological flaws to the
studies and that, as is so often stated in systematic reviews, “more studies are needed.”
[63]
[64]
[64]
A 1989 study of 189 patients with IBS used a 3-week elimination diet that restricted the
intake of 10 foods. Ninety-one people reported improved symptoms, and strikingly, the
number of intolerances noted ranged from 1 to 19 per person. Seventy-two of the 73
patients who reported improvement were found to be well 1 year after the study was
concluded.
[65]
It is reasonable for clinicians to consider eliminating potential problem foods for patients
with IBS, especially those for whom diarrhea is a major symptom. In the first edition of this
text, Manahan observed that in his experience, roughly half of people with IBS seem to
have a dietary component as a cause of symptoms.
[18]
Table 86-3 lists some of the main foods the clinician should consider eliminating in patients
with IBS. Some foods, such as cereal fiber, coffee, and dietary fat, can stimulate motility
quite significantly in many patients.
[47]
Migraine Headache
As Manahan observed, migraine-related food triggers have been studied since the 1930s,
and removal of food triggers is a standard part of integrative therapy for migraine. Some
of the key studies of adverse food reactions in relation to migraine treatment are as follows:
[18]
[1] [66]
•
Balyeat and Brittain found that 29 of 55 patients had complete symptom resolution
when particular foods were avoided. Another 21 of the 55 experienced partial
improvement.
•
In 1935, Sheldon and Randolph reported that two thirds of 127 subjects with migraines
experienced some relief with an elimination diet.
•
A 1979 study found that 85% of a group of 60 migraine sufferers became headache-free
(even though multiple other interventions had failed for many of the subjects) after
following a 5-day elimination of an average of 10 different foods. The total number of
headaches per month for all participants fell from an average of 402 to an average of
just 6.
[67]
[68]
[48]
•
In a blinded study of the role of aspartame (NutraSweet) compared with placebo, there
was a 100% increase in headache frequency during the aspartame consumption phase of
the trial.
[69]
•
Egger and colleagues noted that more than 90% of a group of 88 children with severe
migraine symptoms had response to a food elimination diet.
[70]
For many integrative clinicians, dietary modification is a standard part of any migraine
headache visit. Table 86-3 lists the most common food culprits in migraine headaches.
For any patient with headache, the clinician should consider eliminating aspartame
(NutraSweet) from the diet for a trial period.
Chronic Serous Otitis Media
During the winter cold season, it is not uncommon for patients to present with chronic
middle ear congestion. The evidence favoring the use of elimination diet for serous otitis
media, particularly in children, is worth noting, especially given the limited number of
conservative interventions that are otherwise available to treat this complaint. Nsouli and
coworkers found that in 70 of 81 children (ages 1 to 9 years) with documented food
allergies, there was a significant improvement in tympanometry findings after a 16-week
elimination of specific foods noted to cause each child's adverse reactions.
[49]
In 1997, Derebery and Berliner reported that the majority of their 151 subjects with
eustachian tube dysfunction who had been noted to have evidence of allergies benefited
from an elimination diet. They found a 70% to 83% improvement in symptoms of fullness,
allergic symptoms, and overall well-being. These researchers noted, “Adherence to the
recommended elimination diet was significantly related to outcome.”
[71]
A number of integrative clinicians link dairy and other foods to chronic ear and sinus
congestion, and an elimination diet is worth considering in patients with these problems.
This approach can be beneficial for adults as well as children.
[72]
Rheumatoid Arthritis
Several case reports indicate that diet may have an influence on symptoms of rheumatoid
arthritis. For example, in 1981, the media reported the story of an elderly British woman
with a 25-year history of arthritis pain whose symptoms completely resolved when she
removed corn products from her diet. In the 1960s, the nightshade diet, which eliminates all
of the “nightshade” family vegetables—eggplant, bell peppers, potatoes, and tomatoes—
was quite popular.
[50]
[51]
Manahan reported finding approximately 50 studies exploring the possibility of a link
between adverse food reactions and rheumatoid arthritis. Of 24 studies he reviewed, only 2
did not demonstrate improvement when certain foods were removed from diets of patients
with arthritis. Darlington and colleagues observed that of 70 patients with rheumatoid
arthritis, 19% were able to stay well without medications for 1 to 5 years after eliminating
particular foods that seemed to cause their symptoms. A 2001 randomized trial found that a
9-month or longer gluten-free vegan diet led to a statistically significant improvement in
symptoms for the treatment group in comparison with the control group. One must note,
however, that the use of elimination diets for rheumatoid arthritis remains controversial in
academic circles.
[18]
[52]
[73]
[74] [75] [76]
Prescribing an Elimination Diet
Elimination diets may be useful in a number of common conditions, but currently, the
most favorable evidence supporting their use is in the treatment of ADHD, atopic
dermatitis, diarrhea-predominant IBS, migraines, chronic serous otitis (especially in
children), and, though still controversial in many academic circles, rheumatoid arthritis.
What Is an Elimination Diet?
An elimination diet has been defined as “an investigational short-term or possible lifelong
eating plan that omits one or more foods suspected or known to cause an adverse food
reaction or allergic response.” Elimination diets can serve as both diagnostic and treatment
strategies in an integrative setting. Overall, four principal steps are followed in prescribing
any elimination diet, as outlined previously by Johnson in the first edition of this text.
[77]
[19]
Step 1: The Planning Phase
Before recommending an elimination diet, the clinician must take a thorough patient
history. Ideally, patients should provide a recent dietary log that chronicles what they
typically eat in a week. Descriptions of what symptoms they experience and what times
their symptoms flare should also be noted. Symptoms might range from gastrointestinal
complaints and skin changes to low mood, fatigue, or difficulty with concentration. Table
86-4 lists several issues to address in taking the history of a patient for whom an adverse
food reaction is suspected. A sample 1-week dietary log form is included in the Patient
Handout.
TABLE 86-4 -- Points to Consider before Prescribing an Elimination Diet
Several key questions may
“What foods do you frequently eat?”
reveal which foods should be
“What foods do you crave?”
removed. Examples, as
“What foods make you feel better?”
recommended by Manahan and “What foods would be difficult to give up or go without?”
Johnson19 are as follows:
[18]
A history should also elicit the
following information
:
•
Family history of food intolerance
•
Past medical history of any of the following:
respiratory allergies, chronic upper respiratory
congestion, asthma, atopic dermatitis, infant colic,
gastrointestinal problems (including lactose
intolerance and celiac disease), and unusual reactions
to medications or foods
[1] [18] [19]
[*]
•
History of eating disorders (to avoid the risk that an
elimination diet might exacerbate these conditions)
•
History of food allergies
•
Previous positive laboratory test findings (e.g., results
of skin prick and other allergy tests)
•
Relation of symptoms to exercise (some intolerances
are exacerbated with increased activity)
•
Relation of symptoms to substance use, including
smoking, alcohol, caffeine, and illicit drugs
[†]
•
Life stressors
*
There is evidence that people with certain pollen allergies also have food intolerance. [5] For instance, people with grass pollen allergies may also be allergic to nuts, beans, and/or peas. [1]
†
Some clinicians have noted that the development of food intolerance in some patients is preceded by changes in alcohol tolerance. Patients may first note intolerance to red wine and beer and later an inability
to drink white wine and spirits.[78] Ultimately, intolerance of other food items is noted.
Patients often have a sense of which foods are most likely to contribute to their
symptoms. The clinician should be sure to explore this issue with them.
After a list of potential problem foods is elicited, the next step is to create a list of Foods to
Avoid. The list should be individualized as much as possible for each patient. Table 86-5
lists the foods most likely to cause adverse food reactions; Table 86-3 lists foods linked to
symptoms in various disease states.
TABLE 86-5 -- Common Food Culprits for Food Allergy and Food Intolerance
Food allergy :
Citrus
Dairy products
[*]
[1] [5] [18] [19]
Eggs
Fish
Peanuts
Soy
Gluten (barley, oats, rye, wheat)
Shellfish
Tree nuts (almonds, pecans, walnuts)
Food intolerance: All of the foods listed for food allergy, plus:
Beef products
Corn
Food additives
Antioxidants (butylated hydroxyanisole, butylated hydroxytoluene)
Aspartame (an artificial sweetener; e.g., NutraSweet)
Flavor enhancers (monosodium glutamate)
Food colors (tartrazine and various other Food
Dye and Coloring Act, [FD&C] dyes, which are derived from coal tar)
Nitrates and nitrites (found in preserved meats)
Preservatives (sulfites, benzoates, and sorbates)
Thickeners/stabilizers (tragacanth, agar-aga)
Biogenic amines (histamine, tyramine, octopamine, phenylethylamine)
Disaccharides (lactose)
Foods high in nickel and salicylates (see
Joneja1 for a complete listing)
Refined sugars
*
The foods listed here account for roughly 80% of all food hypersensitivity reactions.
Step 2: The Avoidance Phase
Elimination diets vary in terms of intensity. The type of diet chosen varies according to
the number of suspected food culprits, the likelihood of patient compliance, and the
potential effects of the diet on the patient's nutritional status. The Patient Handout provides
examples of three elimination diets of variable intensity.
[1] [77]
The lowest-intensity elimination diets are referred to as “food-specific diets.” In these, just
one food or group of foods is removed. Which food or foods are to be removed is often
determined on the basis of both patients' suspicions and their responses to the questions
listed in Table 86-4 . For some patients, particularly those for whom maintaining healthy
nutrition may be a challenge, it is most appropriate to pursue several low-intensity
elimination diets, one after another, rather than to remove multiple foods or food groups
simultaneously. However, it should be remembered that some individuals display
intolerance to combinations of foods or food groups; for them, a low-intensity elimination
diet may not prove as useful as a diet in which multiple food groups are removed
simultaneously.
In a moderate-intensity elimination diet, multiple foods or food groups are eliminated.
Patient compliance decreases as diets becomes more restrictive. However, if successfully
done, moderate-intensity diets have the potential to serve as useful diagnostic and
therapeutic tools. The list of foods eliminated is tailored to the individual patient; diseasespecific elimination diets, such as those listed in Table 86-3 , are available in the reference
materials listed at the end of this chapter. Because moderate-intensity elimination diets are
more likely than food-specific elimination diets to lead to symptom resolution, they are
popular with many integrative clinicians.
Finally, a high-intensity, or “few-foods” diet may be considered. In this diet, only the foods
on a specific list may be eaten. Higher levels of supervision are necessary with this type of
diet to ensure that nutritional needs are met. The Patient Handout contains an example of
this diet as well.
[1] [19]
The Patient Handout also provides a table of common “foods in disguise.” When a specific
group of foods are eliminated, some common ingredients that may cause adverse food
reactions must also be eliminated. For example, if a patient is to successfully perform a
dairy elimination diet, he/she must also avoid anything containing whey, caramel, casein, or
semisweet chocolate.
Patients should follow an elimination diet for at least 10 days; some sources even suggest
14 days or longer. It is hypothesized that symptoms caused by food intolerance may not
arise until a few days after the food has been eaten, so it is important to give the foodrelated symptoms time to “wear off” before the foods are re-introduced. A study performed
in 2000 found that in children with cow's milk allergy, there was a delay of 3 to 13 days
between exposure to milk proteins and the onset of clinical reactions, lending support to this
“rule of thumb.”
[1]
[79]
Patients should be warned that with the elimination diet, it is common for symptoms to
worsen before they begin to improve
Step 3: The Challenge Phase
If symptoms decrease during the avoidance phase, it is likely that the food or foods that
were eliminated were in fact contributing to the symptoms. However, symptoms of many
chronic conditions relapse and remit spontaneously, so it is important to re-introduce
eliminated foods after symptoms are gone to see whether or not they recur. Because
symptoms may take a few days to reappear (perhaps because of a delayed IgG response),
foods should be reintroduced back into the diet only every 3 to 4 days. It is best for a patient
to use a small quantity of the re-introduced food at first, then to have a larger serving at
subsequent meals on the same day (assuming no untoward effects are experienced with the
first serving). In addition to chronic symptoms they have had, food-intolerant patients who
re-introduce foods may experience lung congestion, increased mucus production, fatigue,
concentration difficulties, digestive problems, constipation and diarrhea, bloating, fluid
accumulation, mood swings, and/or drowsiness.
[1] [19]
During re-introduction, a previously eliminated food is eaten for only 1 day. It is then
eliminated again if other foods have also been eliminated and need to be re-introduced. The
Patient Handout contains a sample schedule for the elimination and reintroduction of foods
in a moderate-intensity elimination diet.
Improvements in symptoms are readily apparent to the patient when they occur during an
elimination diet. In fact, many patients are quite reluctant to attempt the challenge phase
because their symptoms have improved so markedly.
Step 4: Creating a Long-Term Diet Plan
Once the initial three phases of the elimination diet are completed, long-term diet planning
is necessary. Additional elimination diets may be needed at some point if symptoms are
either unchanged or not fully resolved. Many recommendations exist regarding how long a
food causing adverse reactions should be avoided. A reasonable approach is to continue
the elimination for at least 3 to 6 months. After that, another challenge with the eliminated
food or foods may be attempted. There is some evidence that, when a food is re-introduced
after a lengthy period, a food intolerance may no longer be found. In a study of 10 patients
who had chronic urticaria and/or perennial rhinitis, 38% of the different food intolerances
the subjects had were resolved at retesting a year or more after the initial evaluation.
[1] [51]
[19]
[80]
Risks of Elimination Diets
Although elimination diets are generally safe, particularly when done under the supervision
of a health care professional, a few potential risks must be acknowledged, as follows:
•
Elimination diets might activate “latent” eating disorders. The clinician should screen
patients for anorexia and bulimia nervosa prior to initiating an elimination diet. Patients
with IBS may be especially vulnerable.
[47]
•
A food or food group that has led to an anaphylactic reaction should NEVER be reintroduced. In one small study, fish was eliminated from the diets of seven children;
after they had not consumed it for quite some time the children actually had more florid
hypersensitivity upon re-introduction of fish than they had experienced before it was
eliminated. Although this development is rare, the results of this study must be kept in
mind.
[81]
•
Malnutrition is a risk if a large number of food groups are eliminated. The clinician
must ensure the patient is receiving adequate fiber, nutrients (including vitamin D and
calcium when dairy is restricted), and protein. The patient's weight should be
monitored.
•
The clinician must keep in mind the socioeconomic implications of prescribing an
elimination diet: (1) cost can become prohibitive—for example, various alternatives to
gluten-containing grains can be quite costly or difficult to obtain—and (2) patients
following elimination diets have limited ability to eat at restaurants or other people's
homes, unless their dietary restrictions are clearly understood by those preparing their
meals.
•
Enjoyment of eating may be diminished.
•
The likelihood of patient noncompliance with the diet must always be kept in mind; this
can often be quite high, especially for diets prescribed for children.
The clinician must be mindful of the potential pitfalls of prescribing elimination diets.
Patient compliance, nutritional status, and the psychosocial impacts of such a diet must be
given consideration. Overall, when judiciously used, elimination diets are associated with
minimal risk.
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Patient Handout
Using an Elimination Diet
An elimination diet can be used to determine whether or not certain foods are contributing
to your symptoms. If they are, the diet can also be used as a form of treatment.
There are four main steps to an elimination diet:
Step I: The Planning Phase
You and your health care provider work together to determine which foods might be
causing problems. You may be asked to keep a diet journal for a week, listing the foods you
eat and keeping track of the symptoms you have throughout the day. It is helpful to ask
yourself a few key questions:
•
What foods do I most often eat?
•
What foods do I crave?
•
What foods do I eat to “feel better”?
•
What foods would I have trouble giving up eating?
Often, the foods identified by the answers to these questions seem to be the foods that are
most important to try not to eat. A detailed list of the most common problematic foods is
given later.
Step 2: The Avoidance Phase
For 2 weeks, follow the elimination diet without exception. Foods should be avoided in
their whole form and as ingredients in other foods. For example, if you are avoiding all
dairy products, you need to check labels for whey, casein, and lactose so you can avoid
them as well. This phase takes a lot of discipline. You must pay close attention to food
labels. Be particularly careful if you are eating out, because you have less control over what
goes into the food you eat in a restaurant or another person's house.
Many people notice that in the first week, especially in the first few days, their symptoms
become worse before they start to improve. If your symptoms become severe or increase for
more than a day or two, consult your health care provider.
Step 3: The Challenge Phase
If your symptoms have not improved in 2 weeks, you will need to stop the diet and discuss
whether or not to try it again with a different combination of foods. If your symptoms
improve, however, the next step is to start “challenging” your body with the eliminated
foods, one food or food group at a time. As you do this, keep a written record of your
symptoms.
A new food or food group should be added every 3 days, to give your symptoms time to
come back if they are going to. On the day you introduce an eliminated food back into your
diet for the first time, start with just a small amount in the morning. If you don't notice any
symptoms, eat two larger portions in the afternoon and evening. After a day of eating the
new food, wait for 2 days to see whether you have the symptoms. Then you move on to the
next food.
If a food doesn't cause symptoms during a challenge, it is unlikely to be a problem food and
can be added back into your diet. Don't, however, add that food back until you have tested
all the other foods on your list.
Step 4: Creating a New, Long-Term Diet
On the basis of the results of the first three steps, your health care provider can help you
plan how to eat so that you'll be most likely to prevent your symptoms. Remember:
•
Some people have problems with more than one food.
•
Sometimes symptoms come and go for other reasons, so it can be difficult to tell for
certain whether a specific food is the cause.
•
Be sure that you are getting adequate nutrition during the elimination diet and as you
change your diet for the long term. For example, if you give up dairy, you must
supplement your calcium from other sources.
•
You may need to eliminate several different foods before you identify the ones causing
problems.
•
If a food causes you to have an immediate allergic reaction or causes throat swelling, a
severe rash, or other severe allergy symptoms, it is important to seek the care of an
allergist before re-introducing the problem food.
•
A food intolerance is not always lifelong. Many people are able to slowly re-introduce
eliminated foods 4 to 6 months after eliminating them.
The elimination diet is not a perfect test. A lot of other factors could interfere with the
results (such as a stressful day at work). Try to keep other things in your life as constant as
possible while you are following the diet.
The Three Levels of Elimination Diets
Level 1: The Simple Diet
Eliminate milk, eggs, and wheat, as shown in the following table.
FOODS ALLOWED
Animal proteins Lamb, chicken, turkey, beef, pork
FOODS ELIMINATED
Dairy products Chicken
eggs
Grains and
starches
White potato, sweet potato, yams, rice, tapioca,
Wheat
arrowroot, buckwheat, corn, barley, rye, millet, oats
Fruits
All fruits and juices
Sweeteners
Cane or beet sugar, maple syrup, corn syrup
Oils
Soy, corn, safflower, coconut, vegetable, olive,
peanut, milk-free margarines
Milk-containing butter
and margarines
Salt, all spices
Other
Modified from Joneja JV: Dietary Management of Food Allergy and Intolerance, 2nd ed. Hall
Publishing Group, 1998; and Mahan LK, Escot-Stump S: Krause's Philadelphia, WB Saunders,
2004.
Level 2: The Stricter Diet
The stricter diet eliminates several foods at once.
FOODS ALLOWED
FOODS ELIMINATED
Animal
proteins
Lamb
All others, including eggs and milk
Vegetable
proteins
None
Soy milk, soybeans, peas, other
beans, lentils, peanuts, bean sprouts,
all nuts
Grains and
starches
White potato, sweet potato, yams, rice,
tapioca, buckwheat, arrowroot, corn
Wheat, oats, barley, millet, rye
Vegetables
Most allowed
Peas, tomatoes
Fruits
Most allowed
No citrus or strawberries
Sweeteners
Cane or beet sugar, maple syrup, corn
syrup
Oils
Safflower, coconut, olive, sesame
Other
Salt, pepper, a minimal number of spices, Chocolate, coffee, tea, colas and other
vanilla, lemon extract, baking soda,
soft drinks, alcohol
cream of tartar
Butter, margarine, vegetable oils, soy,
corn, peanut, shortening, all animal
fats
Level 3: A Few-Foods Diet
Only the foods listed here can be eaten; all others are avoided.
•
Rice (including rice cakes and cereal)
•
Pineapple
•
Apricots
•
Cranberries
•
Peaches
•
Pears
•
Apples (juice okay)
•
Lamb
•
Chicken
•
Asparagus
•
Beets
•
Carrots
•
Lettuce
•
Sweet potatoes
•
White vinegar
•
Olive oil
•
Honey
•
Cane or beet sugar
•
Salt
•
Safflower oil
A Sample Elimination Diet Schedule
Below is a sample schedule showing what do to on what day of an elimination diet.
DAY NUMBER STEP
1
Begin elimination diet
2-7
You may notice that symptoms worsen for a day or two
8-14
Symptoms should go away if the right foods have been removed
15
Re-introduce food #1 (for example, dairy)
16-17
Stop food #1 and watch for symptoms
18
Re-introduce food #2 (for example, wheat)
19-20
Stop food #2 again and watch for symptoms
21
Re-introduce food #3
22¼
…and so on, until all eliminated foods have been re-introduced
*
[*]
You re-introduce a new food for only one day; until the diet is over, the food is not added back for good.
Some Helpful Tips
A number of foods can be “disguised” when you look at food labels; they are listed below:
IF YOU ARE
AVOIDING
ALSO AVOID
Dairy
Caramel candy, carob candies, casein and caseinates, custard, curds,
lactalbumin, goat's milk, milk chocolate, nougat, protein hydrolysate,
semisweet chocolate, yogurt, pudding, whey. Also beware of brown sugar
flavoring, butter flavoring, caramel flavoring, coconut cream flavoring, “natural
flavoring,” and Simplesse.
Peanuts
Egg rolls, “high-protein food,” hydrolyzed plant protein, hydrolyzed vegetable
protein, marzipan, nougat, candy, cheesecake crusts, chili, chocolates, pet feed,
sauces.
IF YOU ARE
AVOIDING
ALSO AVOID
Egg
Albumin, apovitellin, avidin, béarnaise sauce, eggnog, egg whites, flavoprotein,
globulin, hollandaise sauce, imitation egg products, livetin, lysozyme,
mayonnaise, meringue, ovalbumin, ovogycoprotin, ovomucin, ovomucoid,
ovomuxoid, Simplesse.
Soy
Chee-fan, ketjap, metiauza, miso, natto, soy flour, soy protein concentrates, soy
protein shakes, soy sauce, soybean hydrolysates, soby sprouts, sufu, tao-cho,
tao-si, taotjo, tempeh, textured soy protein, textured vegetable protein, tofu,
whey-soy drink. Also beware of hydrolyzed plant protein, hydrolyzed soy
protein, hydrolyzed vegetable protein, natural flavoring, vegetable broth,
vegetable gum, and vegetable starch.
Wheat
Atta, bal ahar, bread flour, bulgur, cake flour, cereal extract, couscous, cracked
wheat, durum flour, farina, gluten, graham flour, high-gluten flour, high-protein
flour, kamut flour, laubina, leche alim, malted cereals, minchin, multigrain
products, puffed wheat, red wheat flakes, rolled wheat, semolina, shredded
wheat, soft wheat flour, spelt, superamine, triticale, vital gluten, Vitalia
macaroni, wheat protein powder, wheat starch, wheat tempeh, white flour,
whole-wheat berries. Also beware of gelatinized starch, hydrolyzed vegetable
protein, modified food starch, starch, vegetable gum, and vegetable starch.
Modified from Joneja JV: Dietary Management of Food Allergy and Intolerance, 2nd ed. Hall
Publishing Group, 1998; and Mahan LK, Escot-Stump S: Krause's Food Nutrition and Diet
Therapy, 11th ed. Philadelphia, WB Saunders, 2004.
A One-Week Food Diary Chart
Log in foods eaten and times of day. Note any symptoms you have and their times as well:
DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6
Morning Foods
Morning Symptoms
Morning Symptoms
Afternoon Symptoms
Evening Foods
Evening Symptoms
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