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NANCY ANN COTTER MD, FACN CLINICAL ASSOCIATE PROFESSOR, PMR

RUTGERS NJ MEDICAL SCHOOL CLINICAL CHAMPION, VA NJ

ELIMINATION DIETS

Uncovering hidden food allergies and sensitivities

I HAVE NOTHING TO DISCLOSE………

EDUCATIONAL OBJECTIVES

At the end of this presentation, the participant should be able to: •  Name two discrete mechanisms in which diet is

related to chronic pain •  Name two types of protocols that involve restriction

of specific foods with the goal of uncovering the source or exacerbation of painful symptoms

•  Discuss the phases involved in the classic allergy elimination diet

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HOW PAIN AND DIET ARE RELATED

Food and chronic pain are related through: •  Inflammatory imbalance •  Inflammatory mediators are pain mediators •  Direct links between dietary patterns and pro: anti inflammatory

ratios

•  Microbiome imbalance •  Toxin production •  Candida overgrowth

HOW PAIN AND DIET ARE RELATED

Food and chronic pain are related through:

•  Nutrient imbalance •  Nutrient deficiencies: Mg •  Nutrient deficiency: antioxidants

•  Physiologic Overload •  Enzyme genetically deficient/ lacking •  Upstream nutrients lacking

•  GI- Immune imbalance •  Intestinal wall integrity •  Foods and antigenic mimicking

THE GI-MMUNE SYSTEM

•  A single layer of intelligent cells separates the GI lumen and the circulatory system •  Stranger vs danger ( pathogens, undigested food, toxins) •  Antigen presentation •  Physical barrier / tight junctions

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THE GI-MMUNE SYSTEM

•  Leaky Gut •  Tight junctions may be disrupted •  mechanical damage, inflammatory damage

•  Impaired Barrier •  Undigested, unpresented antigens may “escape” surveillance •  Antigens may be foods, microbes etc •  Cross- reactivity with joint, muscle or organ tissues •  Autoimmunity may be precipitated

WHAT IS AN ELIMINATION DIET?

The temporary adoption of an oligoantigenic diet, deleting potential trigger foods from the diet in order to uncover symptoms that may be caused, exaggerated or maintained by such foods

POPULAR VERSIONS OF ELIMINATION DIETS

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FOOD ALLERGY/ INTOLERANCE/ SENSITIVITY

•  Food allergy •  IgE Antibody- mediated reaction to a food: immediate-type

hypersensitivity. •  IgG Antibody mediated but not strictly a food allergy

•  Food intolerance •  occurs when the enzyme or pathway necessary to metabolize a

nutrient is absent

•  Food sensitivity “catch- all” term for a reaction to food

that can take many forms but is not an immunologic reaction to food

FOOD ALLERGY

•  Food allergy •  IgE Antibody- mediated reaction to a food: immediate-type

hypersensitivity. •  IgG Antibody mediated but not strictly a food allergy

•  Food allergy testing •  Tests IgE antibodies, IgG Antibodies, Mold, Inhalant etc

•  Sensitivity vs specificity

•  High, moderate, low and very low levels of activity

•  Used as a guide to elimination diet

IgG FOOD ANTIBODY TESTING

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FOOD INTOLERANCE/ SENSITIVITY

•  Food intolerance •  Occurs when the enzyme or pathway necessary to metabolize a

nutrient is absent •  Examples:

•  Lactose intolerance- lactase deficiency •  FODMAPS: Fermentable oligosaccharides, disaccharides,

monosaccharides and polyols •  Histamine and tyramine intolerance: inability to break

down histamine or tyramine due to innate genetics or overload

•  Testing is empirical : •  Elimination and reintroduction •  In case of enzyme deficiency: addition of missing enzyme,

or avoidance

•  Food sensitivity •  a term that includes reactions that may currently have no

explanation

WHAT DOES AN ELIMINATION DIET DO?

•  Isolates and removes trigger foods

•  Unburdens the GI system from aggravating / precipitationg factors •  Allow natural restoration

•  Identifies: Potential triggers during add- back period

WHEN TO TRIAL AN ELIMINATION DIET?

•  Multiple chronic intermittent symptoms •  Patient may suggest GI source •  GI pathology •  Symptoms that have no clear explanation •  Family history of food sensitivities and allergies •  If you just don’t know what to do first!

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HOW DO WE ISOLATE TRIGGER FOODS?

FINDING THE NEEDLE IN THE HAYSTACK

WHAT FOODS ARE SUSPICIOUS?

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A FEW TYPES OF ELIMINATION DIETS

JUNK

FREE

CLASSIC

ELIMINATION VERY LOW ANTIGENIC

NO JUNK SOME OF THE

USUAL SUSPECTS

CLASSIC

ELIMINATION

VERY LOW

ANTIGENIC

UNBURDENING

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“HEALTY DIET”

•  Junk elimination Diet

•  Low hanging fruit

•  For those patients who have not monitored diet and in general have a high additive, low fiber, low nutrient diet

•  https://www.choosemyplate.gov

UNBURDENING

THE “USUAL SUSPECTS” DIET(S)

•  The Usual Suspects Diet: Elimination of one specific food or

food group •  Eliminates foods of high suspicion •  Example: lactose, aspartame, gluten, dairy

•  Helpful as a first step for •  Patients who may not be adept at diet modification •  Children •  Patients for whom there is a high index of suspicion due to reported

symptoms with a family history/ genetic predisposition

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CLASSIC ELIMINATION DIET

•  Classic elimination diet: Elimination of several common trigger

foods

•  Eliminates multiple foods known to cause symptoms •  Institute of Functional Medicine Classic Elimination Diet

•  Helpful as a first step for •  Patients who have multiple unexplained symptoms •  Patients who want an efficient elimination and add- back

period •  Patients who have good control over their food intake •  Patients who are activated

STANDARD ALLERGY ELIMINATION DIET PROTOCOL

•  Four phases: •  Planning

•  Restriction period

•  Add back and recording period

•  “New Normal” and Restoration

STANDARD ALLERGY ELIMINATION DIET PROTOCOL

Restriction phase:

•  Wheat, eggs, dairy, soy, corn, tomatoes, shellfish, peanuts, grapefruit, caffeine, additives, highly sugared foods are avoided for 21 days

•  Allowed foods: •  all vegetables except corn and tomatoes •  All fruits except grapefruit •  Lean meats and fish •  Non- gluten containing whole grains

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STANDARD ALLERGY ELIMINATION DIET PROTOCOL

Add- back phase: •  Foods are added back individually and reactions recorded •  Foods with highest index of suspicion are added back first •  The restricted food may be added back up to 3 days in succession •  All reactions are recorded •  If there is a reaction on the first day, there is no need to continue

for Day 2 and 3 •  If there is a reaction, a “washout” period of one day ( or longer as

necessary) is completed before moving to the next food on the list

•  If there is no reaction to the restricted food, it is added back to the diet and no longer restricted

•  Symptom- causing food is avoided for 3-6 months and often

retrialed dependent on clinical picture

STANDARD ALLERGY ELIMINATION DIET PROTOCOL:VARIATIONS

•  Variations during avoidance phase •  should be a minimum of three weeks if IgG involvement is

suspected •  Many patients will want to continue past three weeks if they are

feeling improvement after a long time

•  Variations in allowed foods: •  Add restrictions as suspicions dictate: ie if autoimmune arthritis is

present, avoid nightshades •  If a patient cannot give up a certain food, allow it, and introduce the

idea of a second round, eliminating that food if results are inconclusive

•  Some practitioners restrict all citrus •  Meat vs vegetarian period

•  Variation in rate at which foods are added back may vary according to

response

RESTORATION PHASE(S)

• The Five Rs • Remove • Replace • Reinoculate • Repair • Rebalance

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WHY NOT ELIMINATE ONE FOOD AT A TIME?

CHOOSING THE RIGHT ELIMINATION DIET FOR YOUR PATIENTS

•  Assess understanding of connection between diet and current condition

•  Assess quality of current diet

•  Assess engagement and readiness

•  Assess ability, resources and control over lifestyle

FEW FOODS DIETS

•  Begins with few, well tolerated foods and gradually adds foods once stabilization is reached •  Example: GAPS Diet; Medical Food fasting •  Requires close oversight to prevent nutritional

deficiency •  Used when multiple sensitivities are present •  Patients who have multiple unexplained symptoms •  REQUIRES CLOSE SUPERVISION

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CHOOSING THE RIGHT ELIMINATION DIET FOR YOUR PATIENTS

•  More complex , chronic conditions warrant more restrictive plans

•  Addressing nutritional deficiencies

•  Planning and preparation

•  Record keeping

IN CONCLUSION:

•  Multiple chronic pain conditions may be caused or exacerbated by nutritional patterns and habits

•  There is ample evidence that chronic pain conditions may be ameliorated using nutrition as a foundational part of a comprehensive plan

•  Multiple options exist for systematically trialing nutrition patterns in order to optimize our Integrative approach to healing chronic pain

THANK YOU