Callout to clinicians: Yes, we still prescribe the tried-and-true elimination diet for many people, although we’re aware that increased hypersensitivity can occur in a small subset of individuals. Read on to see how we’re identifying and customizing an elimination plan for these vulnerable individuals. – DrKF
Have you ever noticed that you feel bloated after a meal? Or maybe you have random skin irritations, like rashes or acne. Perhaps you suffer from headaches or migraines and never thought of the food you eat as playing a role. These are all different symptoms; however, they could have one common cause: the food you’re eating.
It is estimated that approximately 20% of the population suffers from some type of food intolerance or sensitivity. These reactions are more common than what’s experienced from a true food allergy. It is important to note the differences. Food allergies are immune-mediated IgE hypersensitivities that can lead to severe reactions such as anaphylaxis. A food sensitivity is also an immunologic reaction to food; however, it is usually mediated by other antibody types – the best researched being IgG, but IgA may also be involved. These types of reactions are typically delayed hypersensitivities – where gas, bloating, fatigue, hives, or headaches may not appear until a few hours are days after ingestion. Food intolerances are non-immune mediated, rather they typically come from trouble digesting a food, such as with lactose intolerance. The elimination diet is the gold standard for helping to identify food reactivity. This therapeutic dietary intervention can help determine foods a person may be sensitive or allergic to as well as allow the gastrointestinal and immune system appropriate time for rest and healing.
When people hear mention of an elimination diet, their first thought tends to be “what am I going to eat?” If you’ve ever tried one, you know that it can seem daunting at first. However, with a few tips, the process can go a whole lot more smoothly.
Who would an elimination diet benefit?
The short answer is anyone experiencing symptoms following ingestion of certain foods. It is more nuanced than that though, and important to remember there are different types of elimination diets as well. As with most nutritional interventions, one size doesn’t fit all.
If you experience chronic symptoms it could well be due to foods you had been eating on a regular basis. Without realizing it, they may be causing you problems, such as digestive issues, skin conditions, brain fog, fatigue, insomnia, and even joint pain.
Dairy seems to be a frequent player in acne and might take a little longer to clear up. So if you have acne and are embarking on a dairy-elimination, stick with it! – DrKF
Those suffering from digestive disorders, such as irritable bowel syndrome (IBS) or eosinophilic esophagitis*, often find they have some type of food reaction that contributes to their symptoms. Those with IBS who performed an elimination diet based on IgG antibodies to specific foods (a test that we and many other functional medicine practices regularly use) were found to exhibit an overall decrease in symptoms. The most common foods excluded were yeast, eggs, cashews, milk, and wheat. Interestingly, many of those same foods can be a trigger for those experiencing eosinophilic esophagitis. Dietary avoidance shows that food can play a large role in eosinophilic esophagitis.
Those that suffer from headaches, especially migraines, have found that eliminating certain foods can decrease their headache severity. Cheese, chocolate, citrus, alcohol, coffee, certain carbohydrates, and red wine are some of the potential triggers for migraine sufferers.
In my experience treating migraineurs, two thoughts come to mind: 1) food reactions are always a piece of the puzzle, although there may be other triggers as well. 2) My most significant cases (one had a 50-year history of near-daily headaches—I worked with her at a tertiary care pain center) had egg as the primary trigger. – DrKF
Elimination diets have also been used with success in children with ADHD. The most common elimination foods in this instance are gluten and dairy.
As you can see, many different types of elimination diets exist (even more than we can list here), and each person may have different foods that are their trigger. This underscores the importance of working with a functional medicine-trained nutritionist to aid in the management and successful administration of an elimination diet.
There are two concerns when undertaking an elimination diet without support from an experienced nutritionist: 1) You don’t select the correct foods and it fails. 2) You omit too many foods for too long and develop nutrient imbalances. We commonly see both of these in practice. – DrKF
How to conduct an elimination diet
An elimination diet is your own “n of 1” experiment. The more rigorous you are in following the “protocol” the better the outcome and more you’ll learn about how foods affect you. Done correctly, an elimination diet is one of the most powerful tools in functional medicine. – DrKF
Although all of the food plans we use here at the clinic are personalized and sometimes layered together, a cornerstone is the basic Sandy Hook Elimination diet. Here, we remove the most common food groups that tend toward reactivity. We specifically target seven food groups: corn, dairy, eggs, gluten-containing foods, peanuts, shellfish, and soy. As part of a basic healthy lifestyle and to aid in healing potential underlying causes of food sensitivities (e.g., establishing better immune regulation), we also emphasize high amounts of whole foods including low glycemic vegetables and fruits, high-quality meats and fish, along with nuts, seeds, herbs, and spices.
After a specified time on the plan, typically 4-6 weeks, we begin to intentionally challenge each food group to determine which might be causing symptoms. It’s important to root this out so that someone’s diet can be as expansive, and comprehensive as possible long-term with the least food groups intentionally avoided.
What does “intentionally challenge” mean? Well, instead of just adding in all those food groups at once, we begin by adding in one group at a time. This allows us to tease out any reactions to the individual foods. Challenging each food takes 4 days total: 2 days of eating the food and 2 days of observing for any reactions, such as constipation, diarrhea, headaches, congestion. A typical challenge may look something like this:
- Day 1: Shrimp – 1 at breakfast, 1 at lunch, 4 in the late afternoon
- Day 2: Shrimp – 2 at breakfast, 2 at lunch, 4 in the late afternoon
- Days 3 & 4: stop eating shrimp but do not challenge any other food
- Days 1-4: observe and record symptoms throughout. Stop the challenge process if you record definite symptoms
Note, if you have a true food allergy, you should not follow any challenge process unless under the specific guidance of your allergist.
Navigating obstacles to make your elimination diet a success
The greatest challenge we observe for our clients is to manage to completely avoid these foods for the 4-6 week elimination period. Some of the reasons for this include other household members who aren’t in need of or do not support dietary change, social events such as parties or dinner with friends (at least pre-COVID), overnight travel (again, pre-COVID), and even those days where you just need a break from cooking so you end up ordering food from restaurant take-out menus.
Here are few common challenges we typically see and our tips for how to navigate them. No one has to eat just salad for 4 weeks!
Challenge 1: I cook for my spouse/children/significant other and don’t want to have to make two meals all the time.
We know how important family mealtime is, and no one wants to prepare two meals or feel like they are missing out on what their other family members are having. Many recipes can be adapted to be elimination diet-friendly. Love Asian-inspired meals? Instead of soy sauce try coconut aminos. Italian more your style? Try using spaghetti squash or zucchini noodles in place of regular pasta. Are you a big taco Tuesday fan? Leave the corn taco shells and tortillas for your family and enjoy the rest of the meal on a bed of fresh spinach or diced jicama with some extra guacamole.
Challenge 2: No eggs? What do I have for breakfast?
Yes, technically a gluten-free oatmeal or granola could be compatible with your elimination diet. But what if I told you that you can have the same foods you have for lunch and dinner for breakfast? We commonly think of eggs, cereals, and pastries as our options for breakfast foods, however, the term breakfast is really just breaking your fast from the night before. If you think of it this way, the food possibilities are endless. A few uncommon breakfast ideas could be:
- Homemade turkey or salmon patties, maybe from dinner the night before, with wilted greens.
- Roasted sweet potatoes or butternut squash pureed with bone broth; a warm and satisfying drink for the morning.
- Miso soup with vegetables and chickpeas, made with chickpea or other non-soy miso.
Challenge 3: I work full-time, how am I supposed to prep and cook all this food?
Even if you don’t work full-time, prepping and cooking food every day can seem like a daunting task. One of my favorite tips is batch cooking, taking a free day and making foods that could be easily portioned out or frozen to use throughout the week. Roasted vegetables, turkey meatballs, and quinoa are just a few options that can all be made ahead of time. They are easy to warm and flavors can be changed up by adding different spices or dressings on different days. Check out our nutritious recipes for some inspiration!
Is cooking really not your thing? There are plenty of meal delivery services available; Pete’s Paleo and Kettlebell Kitchen offer pre-made meals that can be compatible with an elimination diet, just remember to check ingredients before you order. Sun Basket or Green Chef are good options for both pre-made meals or meal kits if you don’t mind some prep work.
Challenge 4: What if I want to enjoy a night out or have take-out? Is my only safe option a salad?
This is one of the most common questions we get. I can assure you, you can still eat at a restaurant, or order carry-out – the key is to do your research before you go or order. With the advent of many different types of dietary styles becoming more mainstream, restaurants have taken notice. Many have updated their menus to specify options that are gluten-free, dairy-free, or soy-free. However, keep in mind this may not mean those options are completely elimination diet-friendly, but it’s a good place to start.
The following tips can help you navigate ordering food out while still sticking to your elimination diet.
- Check out the menu online. Most, if not all, restaurants have an online presence. Reading through their menu ahead of time, and asking if they have an allergy menu, can help you decide which foods could be an option for you.
- Ask about substitutions. You can call ahead or ask when you get there, but many chefs are happy to offer an alternative to a food you cannot eat. Does a dish come with a side of pasta? Ask if you can have steamed vegetables instead. Is the meat or fish cooked in butter? Find out if they can cook it in olive oil. At a burger place? Order it without the bun perhaps opting for a lettuce wrap, instead of cheese add some sauteed onions or guacamole, have a baked potato instead of French fries.
- Ask questions. If you aren’t sure what is in a dish, don’t be afraid to ask. Even if the wait staff isn’t sure, the chef will know what they put in their food. They might use coconut milk instead of cream in some dishes, but if you don’t ask, you don’t know.
- Do your research. Sites such as com or TripAdvisor.com can help narrow down restaurants that are dietary restriction friendly. Plus, you can read up on their reviews to find out what foods are the best and what to avoid.
As Alexander Graham Bell said, “Preparation is the key to success;” if you are prepared, you will spend less time worrying about what you are going to eat and more time enjoying the company you are with.
While it can be challenging, navigating an elimination diet doesn’t have to be stressful. If you prepare and plan ahead, you can move through the weeks successfully and before you know it, it will be time to begin expanding your diet. However, we strongly recommend working with a functional medicine-trained nutritionist that is familiar with elimination diets. Our Nutrition Team (fully-trained in the functional medicine approach) is especially skillful in leading clients through the elimination and challenge phases by providing support and offering resources and recipes that can make transitions seamless.
Related: Check out our article about how to travel while on an elimination diet here. Also, check out these nutritional and lifestyle tips to improve eosinophilic esophagitis and learn about our approach to healing the gut with our 6R Gut Program.
*Individuals who have a history of allergic disease such as atopic eczema, asthma, food allergy, hay fever, or eosinophilic esophagitis/gastroenteritis should only undertake an elimination diet after consultation with a qualified practitioner. There is some risk for increased reactivity in those individuals and so we approach an elimination diet differently, often using microdosing to achieve near-elimination with a controlled amount of the reactive food to avoid increasing the immune response upon challenge. Products such as Spoonful One work well for this.
It appears that a very small exposure to the problem food(s) during the elimination period can help maintain any background immune tolerance that exists while also providing symptom relief because the overall quantity of antigenic food is reduced. Note that a full 5/6-R gut restoration program should be used concurrently in this population. – DrKF