Elimination Diet
In my previous article about food sensitivities I alluded to the elimination diet as an approach to reduce them. Let’s dig deeper to understand what the elimination diet is, who should attempt it and what to expect from following this diet.
The Elimination Diet has been used in clinical practice by functional medicine providers since the early 1990’s. It is an oligoantigenic diet meaning that it reduces the antigens to which IGG antibodies are produced by people who suffer from food sensitivities and also from altered intestinal permeability thus reducing local and systemic symptoms. (1) (2)
What is the Elimination Diet?
The Elimination Diet excludes common foods that have pro-inflammatory effects in susceptible individuals. These diets will vary from one source to another but often exclude similar foods. (1)(8)(3)(29)
The excluded foods are :
- Gluten
- Dairy
- Corn
- Soy
- SugarAlcohol
- Coffee
- Eggs
- Peanuts
- Shrimp and shellfish
- Nightshade vegetables such as tomatoes, potatoes, eggplants and peppers
- Preservatives and additives
Let’s take these foods one by one and see what kind of evidence supports the exclusion of these foods.
Gluten
There is so much litterature on the harmful effects of gluten, and what kind of clinical issues this may cause. Gluten is best known and understood from the point of view of Celiac disease which is an extreme form of allergy to gluten and it manifests with marked inflammatory changes on gastroscopy; Celiac disease can lead to dangerous complications such as cancer and its treatment is lifelong exclusion of gluten from the diet. The work of Alessandro Fasano MD in the early 2000s informed our understanding of altered intestinal permeability when it comes to consumption of gluten. The work of Dr Hadjivssiliou and collegues (9) (10) has linked gluten sensitivity to neurological disease and studied its partial reversal on a gluten free diet. Since then, more studies have enabled our understanding of other conditions that are linked to gluten outside of Celiac such as hydradenitis suppurativa (11) and cognitive decline (13) as well as some cases of autism (12). According to this (14) and this (15) study every single person who eats gluten experiences some degree of altered intestinal permeability, and that resolves within a few hours in an otherwise healthy person.
The work of Dr William Davis in Wheat Belly (16) exposes the addictive nature of grains and of wheat in particular as well as its role in the obesity epidemic we see in the developed world today due to an altered blood sugar metabolism. Grain brain by Dr David Perlmutter exposes the harmful effects of grains on our memory, retention, focus and other aspects of brain health. (13)
The link between gluten and other auto-immune diseases such as Hashimoto thyroiditis (17) or Psoriasis (18) has been studied and gluten is postulated to exacerbate these conditions by furthering abnormal gut permeability.
Dairy
This food contains 3 proteins that have antigenic proprieties: casein, whey and lactose. Lactose free products still contain casein and whey and although they do not cause direct IBS symptoms they frequently cause food sensitivities. The symptoms linked to this is often increased nasal congestion, worsening eczema, as well as asthma/ bronchitis.
Casein is a gluteomorphine that has addictive proprieties similar to opioids in fact. (19)(20). If this is the case, no wonder people have such trouble weaning themselves from dairy products, especially cheese! It gives them a « high »!
Nightshade vegetables
This group of vegetables, although rich in anti-oxidants also contain solanins, saponins, lectins and glycoalkoids. Although peer reviewed placebo controlled studies are lacking in this field, there is supportive evidence that some of these phytochemicals are associated with altered intestinal permeability or otherwise intestinal inflammation. (21)(22). Furthermore solanine affects the microbiome in favour of certain micro-organisms that promote inflammation in select individuals. A study by Lablokov (23) determined that the individuals who eat potatoes, particularly in the form of french fries worsen the intestinal inflammation associated with IBD. (7)(6)(5)(4)
Alcohol
This item seems self explanatory. We have numerous studies detailing the toxic effects of alcohol consumed in large amounts, from cirrhosis and alcohol induced hepatitis, to delirium and frank dementia, to heart failure. All are pretty bad. Yes, in truth they are due to overuse of alcohol, but regular casual use is fine, right? Well, it depends. First casual use is defined as less than 7 drinks per week for women and less than 14 drinks per week for men, and it is easy to drink more if alcohol is consumed regularly. Second, even in very moderate consumers, subtle signs of toxicity can be found in the CBC in the form of macrocytosis, which is an enlarged appearance of red blood cells and can occur in the context of alcohol toxicity; other subtle but notable signs are in the sensation of the distal extremities, the first sign of toxicity to the nerve endings in the feet being the loss of vibratory sense. This clinical test is done by applying an object that vibrates onto the patient’s toe, and placing the index finger under the toe, the doctor asks the patient to tell him when the vibration stops, with a loss of vibratory sense the patient tells the clinician that the object is no longer vibrating when in fact it still is. Given all these considerations pertaining to the toxic effects of alcohol, the elimination diet excludes it.
Sugar
This should also be self explanatory at this point. We are referring here to added sugar in food and not to naturally occurring sugars. Added sugar, whether brown or white whether low or regular calories is inflammatory and raises the HbA1C. This is a hemoglobin that is glycated, meaning a sugar molecule was added to a hemoglobin molecule. This occurs naturally but it is not a desired phenomenon and we should strive to keep our HbA1C as low as possible for optimal health. Too much sugar raises the insulin and leads to insulin resistance which causes a host of problems on its own. Also, added sugar changes the microbiome in favour of less beneficial species to the host and can lead to growth of candida in the gut for example. Numerous studies have evaluated the negative effects of added sugar and I will cover this topic in greater details in subsequent blogs but for now sugar is out of this diet.
The degree of evidence for some of the other foods in this elimination diet is less well researched in studies but rather comes from expert advice and from the experience of functional medicine practitioners who have been treating patients for the past 30 years.
Corn
This convenience sweet food is into everything these days, from high fructose corn syrup to modified maize protein to cornmeal or even corn flakes. It is produced massively in North America and is even overproduced thus leaving the excess to be used wisely by food scientists to add into convenience foods mostly to sweeten the deal. With a « regular » diet, also called standard American diet or SAD diet, the likelihood that a person suffering from food sensitivities is eating corn regularly is high. This food is therefore likely to be a problem food and is best eliminated and challenged.
Soy
Also a mass produced crop, it is ubiquitary in conventional farming fields. This food staple is rich in protein and can be turned into almost anything with the right flavours. It appears in convenience foods under many names including tempeh, hydrolyzed soy protein, soy sauce and tamari. Bought intact it is also called edamame. Given its omnipresence in foodstuffs, it is likely a problem food and best eliminated and challenged, same as for corn.
Coffee
Caffeinated products raise cortisol, our survival hormone which gives us a boost of energy. Unfortunately this boosts comes with increased inflammation throughout the body which can also be present in the gut. High cortisol also negatively impacts the microbiome, which in turn leads to a negative impact on the immune system. (24) Caffeine can also negatively impact sleep which is so foundational in any healing journey. Furthermore coffee is addictive (25) and people often experience withdrawal symptoms when weaning off from it. For all these reasons, coffee is usually excluded as part of the elimination diet.
Food additives and preservatives
These are ubiquitary in foodstuffs and frequently there are no safety studies done on these chemicals before being introduced on the market. And when these studies exist, they are usually done on the short term, looking at 3 months of exposure but never years. In the long term we therefore have no information about how this will affect our bodies and our health. Therefore prudence dictates to eliminate these common items from the elimination diet and challenge them later.
Eggs
Eggs are not inherently bod, quite the contrary! Unfortunately eggs can be a source of sensitivity and an allergen (26) and given the high prevalence of reactivity to eggs, they are eliminated as part of this diet. (27)(38)(39)
Shrimp and shellfish as well as Peanuts
These are unequivocally problem foods for many people suffering from dietary allergies. (26) They lead to anaphylaxis, which is the most dangerous allergic reaction of all and can lead to respiratory failure and death. These foods can lead to IGG antibodies formation in individuals with various skin conditions (28) which may impact the disease process. In functional medicine practice I have observed that elimination of IGG to foods leads to improved clinical outcomes in a number of seemingly unrelated health issues.
How long should the elimination diet be followed for?
In order to reduce the symptoms associated with food sensitivities, the diet needs to be followed for a minimum of 3-4 weeks. When IGG antibodies are produced by the immune system to various foods, their half-life is 30 days; this is true of all IGGs produced. Therefore in order to reduce these IGGs from the general circulation, we need to stop consuming the offending foods for long enough, 4 weeks essentially. After 4 weeks we will have roughly 1/2 the antibodies to foods than we did at the onset of the elimination diet. Of course this diet can be continued for longer durations up to 3 months if desired. (32)(30)
How to re-introduce foods back into the diet
Once the elimination diet period is up, we need to challenge the foods eliminated. This is best done one food at the time every 3 days. Example: challenged food is coffee. Coffee is consumed liberally on day 1 and then no coffee on day 2 and 3 while monitoring for any symptoms; if no problematic symptoms come back, coffee is re-introduced starting on day 4 while a new food, say eggs, is challenged. The whole process of re-introduction takes approximately 2.5 weeks but may be longer depending on what type of symptoms return. The rule of thumb is that it is best to wait until any uncomfortable symptom has resolved prior to challenging any new food. Example: tomatoes are introduced on day 1 and on day 2 you notice joint pains, on day 2 and 3 no tomatoes are consumed but it takes up to day 5 for the joint pain to resolve, you can challenge the next food on day 6 in this scenario.
How to be successful at completing this diet
When re-introducing foods make sure you pick foods that are simple and contain only that ingredient. Example in order to re-introduce coffee have it black instead of adding dairy in it since that might trigger symptoms. Or to re-introduce soy try edamame instead of soy sauce since the latter often contains gluten as well.
Make sure to avoid going hungry. Some foods especially high sugar foods have the potential, when removed from the diet to cause symptoms apparent to hypoglycemia. They usually present with irritability, cravings, trouble concentrating and occasionally tremors or sweats. If you are not diabetic and are not on sugar lowering medications then this will not be dangerous but it is unpleasant. In order to avoid these cravings it is best to have available various healthy snacks throughout the day like veggies and hummus or nuts or a coconut yogourt or a salad etc.
Plan ahead and have various pre-prepared ingredients for easy use.
Example: prepare lentils and rice ahead of time, boil some sweet potatoes or some salmon and store it in your fridge. You can pre-cut some carrots, radishes, celery and onion and toss them in the pan along with the lentils for a quick veggie saute that is tasty and filling.
Also stock up on seeds and nuts. Hemp seeds can be added to soups and salads and so can flax seeds or pumpkin seeds, all will add flavour and fiber to enhance fullness and help support the gut microbiome
For recipes following the principles of the elimination diet, please stay tuned for more content. In the meantime, for inspiration please consult the references I added under Recipes below.
What to do long term with the information acquired from this
At the end of the process, once all the foods have been re-introduced, you have a much better idea which foods are problem foods for you and which foods are safe to consume daily. This information will give you agency to act upon and it will give you control over your symptoms. You may not choose to follow the diet after this whole process but at least if you have identified that gluten and dairy are problem foods, the next time you eat a bowl of pasta at the restaurant and subsequently get a disturbed transit or extra pimples you will know why. And, when you are ready to commit to your long term version of the elimination diet, you will know what that looks like and it will be easier to do. Also, remember that every 3 months you should challenge the problem foods again and see if they are still problematic; things change over time and some problem foods stop being an issue when consumed occasionally.
Recipes
Here are some links to recipes that you can follow while on the elimination diet, most of them are vegeterian and contain few inflammatory ingredients:
Some recipes may contain foods restricted in the elimination diet, so please be careful and selective.
References:
(1) IFM: Heal the Gut With the IFM Elimination Diet. https://www.ifm.org/news-insights/toolkit-heal-microbiome-ifm-elimination-diet/
(2) Abbott RD, Sadowski A, Alt AG. Efficacy of the Autoimmune Protocol Diet as Part of a Multi-disciplinary, Supported Lifestyle Intervention for Hashimoto's Thyroiditis. Cureus. 2019 Apr 27;11(4):e4556. doi: 10.7759/cureus.4556. PMID: 31275780; PMCID: PMC6592837.
(3) Elimination Diet from the University of Wisconsin-Madison School of Medicine and Public Health https://www.fammed.wisc.edu/files/webfm-uploads/documents/outreach/im/handout_elimination_diet_patient.pdf
(4) Friedman M. Potato glycoalkaloids and metabolites: roles in the plant and in the diet. J. Agric. Food Chem. 2006;54:8655–8681. [PubMed] [Google Scholar]
(5) Mensinga T.T., Sips A.J., Rompelberg C.J., van Twillert K., Meulenbelt J., van den Top H.J., van Egmond H.P. Potato glycoalkaloids and adverse effects in humans: an ascending dose study. Regul. Toxicol. Pharmacol. 2005;41:66–72. [PubMed] [Google Scholar]
(6) El-Tawil A.M. Prevalence of inflammatory bowel diseases in the Western Nations: high consumption of potatoes may be contributing. Int. J. Colorectal Dis. 2008;23:1017–1018. [PubMed] [Google Scholar]
(7) Patel B., Schutte R., Sporns P., Doyle J., Jewel L., Fedorak R.N. Potato glycoalkaloids adversely affect intestinal permeability and aggravate inflammatory bowel disease. Inflamm. Bowel Dis. 2002;8:340–346. [PubMed] [Google Scholar]
(8) Bustamante MF, Agustín-Perez M, Cedola F, Coras R, Narasimhan R, Golshan S, Guma M. Design of an anti-inflammatory diet (ITIS diet) for patients with rheumatoid arthritis. Contemp Clin Trials Commun. 2020 Jan 21;17:100524. doi: 10.1016/j.conctc.2020.100524. PMID: 32025586; PMCID: PMC6997513.
(9) Hadjivassiliou M, Grünewald RA, Davies-Jones GA. Gluten sensitivity as a neurological illness. J Neurol Neurosurg Psychiatry. 2002 May;72(5):560-3. doi: 10.1136/jnnp.72.5.560. PMID: 11971034; PMCID: PMC1737870.
(10) Zis P, Hadjivassiliou M. Treatment of Neurological Manifestations of Gluten Sensitivity and Coeliac Disease. Curr Treat Options Neurol. 2019 Feb 26;21(3):10. doi: 10.1007/s11940-019-0552-7. PMID: 30806821.
(11) Smecuol E, Sugai E, Niveloni S, Vázquez H, Pedreira S, Mazure R, Moreno ML, Label M, Mauriño E, Fasano A, Meddings J, Bai JC. Permeability, zonulin production, and enteropathy in dermatitis herpetiformis. Clin Gastroenterol Hepatol. 2005 Apr;3(4):335-41. doi: 10.1016/s1542-3565(04)00778-5. PMID: 15822038.
(12) Genuis SJ, Bouchard TP. Celiac disease presenting as autism. J Child Neurol. 2010 Jan;25(1):114-9. doi: 10.1177/0883073809336127. Epub 2009 Jun 29. PMID: 19564647.
(13) Grain brain, by David Perlmutter MD, neurologist. Published 2013 by Hachette Book group https://www.amazon.com/gp/product/0316485136/ref=as_li_tl?ie=UTF8&camp=1789&creative=9325&creativeASIN=0316485136&linkCode=as2&tag=wwwdrperlmutt-20&linkId=0ca8e41a73f1de80cc8a2f2a1d80d514
(14) Fasano A. All disease begins in the (leaky) gut: role of zonulin-mediated gut permeability in the pathogenesis of some chronic inflammatory diseases. F1000Res. 2020 Jan 31;9:F1000 Faculty Rev-69. doi: 10.12688/f1000research.20510.1. PMID: 32051759; PMCID: PMC6996528.
(15) Drago S, El Asmar R, Di Pierro M, Grazia Clemente M, Tripathi A, Sapone A, Thakar M, Iacono G, Carroccio A, D'Agate C, Not T, Zampini L, Catassi C, Fasano A. Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines. Scand J Gastroenterol. 2006 Apr;41(4):408-19. doi: 10.1080/00365520500235334. PMID: 16635908.
(16) Wheat belly book, Dr William Davis. https://www.amazon.com/Wheat-Belly-Revised-Updated-Weight/dp/1984824945/ref=sr_1_5?keywords=wheat+belly&qid=1573142853&sr=8-5
(17) Krysiak R, Szkróbka W, Okopień B. The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto's Thyroiditis: A Pilot Study. Exp Clin Endocrinol Diabetes. 2019 Jul;127(7):417-422. doi: 10.1055/a-0653-7108. Epub 2018 Jul 30. PMID: 30060266.
(18) Bhatia BK, Millsop JW, Debbaneh M, Koo J, Linos E, Liao W. Diet and psoriasis, part II: celiac disease and role of a gluten-free diet. J Am Acad Dermatol. 2014 Aug;71(2):350-8. doi: 10.1016/j.jaad.2014.03.017. Epub 2014 Apr 26. PMID: 24780176; PMCID: PMC4104239.
(19) Lister J, Fletcher PJ, Nobrega JN, Remington G. Behavioral effects of food-derived opioid-like peptides in rodents: Implications for schizophrenia? Pharmacol Biochem Behav. 2015 Jul;134:70-8. doi: 10.1016/j.pbb.2015.01.020. Epub 2015 Feb 7. PMID: 25661529.
(20) Teschemacher H, Koch G, Brantl V. Milk protein-derived opioid receptor ligands. Biopolymers. 1997;43(2):99-117. doi: 10.1002/(SICI)1097-0282(1997)43:2<99::AID-BIP3>3.0.CO;2-V. PMID: 9216246.
(21) Salehi B, Sharifi-Rad R, Sharopov F, Namiesnik J, Roointan A, Kamle M, Kumar P, Martins N, Sharifi-Rad J. Beneficial effects and potential risks of tomato consumption for human health: An overview. Nutrition. 2019 Jun;62:201-208. doi: 10.1016/j.nut.2019.01.012. Epub 2019 Jan 25. PMID: 30925445
(22) Could Plant Lectins Be Hurting Your Gut? A Doctor Explains by William Rowls MD; https://www.mindbodygreen.com/articles/could-plant-lectins-be-hurting-your-gut
(23) Iablokov V., Sydora B.C., Foshaug R., Meddings J., Driedger D., Churchill T., Fedorak R.N. Naturally occurring glycoalkaloids in potatoes aggravate intestinal inflammation in two mouse models of inflammatory bowel disease. Dig. Dis. Sci. 2010;55:3078–3085. [PubMed] [Google Scholar]
(24) Norager CB, Jensen MB, Weimann A, Madsen MR. Metabolic effects of caffeine ingestion and physical work in 75-year old citizens. A randomized, double-blind, placebo-controlled, cross-over study. Clin Endocrinol (Oxf). 2006 Aug;65(2):223-8. doi: 10.1111/j.1365-2265.2006.02579.x. PMID: 16886964.
(25) Gahr M. Koffein, das am häufigsten konsumierte Psychostimulans: eine narrative Übersichtsarbeit [Caffeine, the most frequently consumed psychostimulant: a narrative review article]. Fortschr Neurol Psychiatr. 2020 May;88(5):318-330. German. doi: 10.1055/a-0985-4236. Epub 2019 Oct 14. PMID: 31610604.
(26) Vinit C, Dieme A, Courbage S, Dehaine C, Dufeu CM, Jacquemot S, Lajus M, Montigny L, Payen E, Yang DD, Dupont C. Eosinophilic esophagitis: Pathophysiology, diagnosis, and management. Arch Pediatr. 2019 Apr;26(3):182-190. doi: 10.1016/j.arcped.2019.02.005. Epub 2019 Mar 1. PMID: 30827775.
(27) Bath-Hextall F, Delamere FM, Williams HC. Dietary exclusions for improving established atopic eczema in adults and children: systematic review. Allergy. 2009 Feb;64(2):258-64. doi: 10.1111/j.1398-9995.2008.01917.x. PMID: 19178405.
(28) Yin'e H, Shufang D, Bin W, Wei Q, Junling G, Ashraf MA. Analysis of the relations between allergen specific LgG antibody and allergic dermatosis of 14 kinds foods. Open Med (Wars). 2015 Dec 17;10(1):405-409. doi: 10.1515/med-2015-0070. PMID: 28352727; PMCID: PMC5368856.
(29) Xie Y, Zhou G, Xu Y, He B, Wang Y, Ma R, Chang Y, He D, Xu C, Xiao Z. Effects of Diet Based on IgG Elimination Combined with Probiotics on Migraine Plus Irritable Bowel Syndrome. Pain Res Manag. 2019 Aug 21;2019:7890461. doi: 10.1155/2019/7890461. PMID: 31531150; PMCID: PMC6721378.
(30) Visser J, Rozing J, Sapone A, Lammers K, Fasano A. Tight junctions, intestinal permeability, and autoimmunity: celiac disease and type 1 diabetes paradigms. Ann N Y Acad Sci. 2009 May;1165:195-205. doi: 10.1111/j.1749-6632.2009.04037.x. PMID: 19538307; PMCID: PMC2886850.
(31) Miglietta S, Borghini R, Relucenti M, Sorrentino V, Chen R, Li X, Fazi F, Donato G, Familiari G, Petrozza V, Picarelli A. New Insights into Intestinal Permeability in Irritable Bowel Syndrome-Like Disorders: Histological and Ultrastructural Findings of Duodenal Biopsies. Cells. 2021 Sep 29;10(10):2593. doi: 10.3390/cells10102593. PMID: 34685576; PMCID: PMC8533783.
(32) Fasano A. Leaky gut and autoimmune diseases. Clin Rev Allergy Immunol. 2012 Feb;42(1):71-8. doi: 10.1007/s12016-011-8291-x. PMID: 22109896
(33) Atkinson W, Sheldon TA, Shaath N, Whorwell PJ. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut. 2004 Oct;53(10):1459-64. doi: 10.1136/gut.2003.037697. PMID: 15361495; PMCID: PMC1774223.
(34) Dhar S, Srinivas SM. Food Allergy in Atopic Dermatitis. Indian J Dermatol. 2016 Nov-Dec;61(6):645-648. doi: 10.4103/0019-5154.193673. PMID: 27904183; PMCID: PMC5122280.
(35) Pacor ML, Peroli P, Nicolis F, Bambara LM, Givanni S, Marrocchella R, Lunardi C. Eczema e allergia alimentare nell'adulto [Eczema and food allergy in the adult]. Recenti Prog Med. 1990 Mar;81(3):139-41. Italian. PMID: 2359866.
(36) Konijeti GG, Kim N, Lewis JD, Groven S, Chandrasekaran A, Grandhe S, Diamant C, Singh E, Oliveira G, Wang X, Molparia B, Torkamani A. Efficacy of the Autoimmune Protocol Diet for Inflammatory Bowel Disease. Inflamm Bowel Dis. 2017 Nov;23(11):2054-2060. doi: 10.1097/MIB.0000000000001221. PMID: 28858071; PMCID: PMC5647120.
(37) Syrigou E, Angelakopoulou A, Zande M, Panagiotou I, Roma E, Pitsios C. Allergy-test-driven elimination diet is useful in children with eosinophilic esophagitis, regardless of the severity of symptoms. Pediatr Allergy Immunol. 2015 Jun;26(4):323-9. doi: 10.1111/pai.12389. PMID: 25845555.
(38) Vashi R, Hirano I. Diet therapy for eosinophilic esophagitis: when, why and how. Curr Opin Gastroenterol. 2013 Jul;29(4):407-15. doi: 10.1097/MOG.0b013e328362285d. PMID: 23689524.
(39) Spergel JM, Andrews T, Brown-Whitehorn TF, Beausoleil JL, Liacouras CA. Treatment of eosinophilic esophagitis with specific food elimination diet directed by a combination of skin prick and patch tests. Ann Allergy Asthma Immunol. 2005 Oct;95(4):336-43. doi: 10.1016/S1081-1206(10)61151-9. PMID: 16279563.