Elimination Diet: A Valuable Disclaimer?

[MikeyG]

Dear Jeff,

I hope that this message finds you very well.

I shared the following concern with a loved one who was tempted to try an elimination diet, and I was hopeful that you might be kind enough to share your perspective.

Do you think this is an issue that those of us considering elimination diets should be aware of? Does my hypothesis seem plausible in that many "food intolerances," especially those observed while undertaking an elimination diet, may simply be the result of our bodies needing more time to adapt to changes in diet?

Thank you very much for your consideration and for all that you do to support global health.

Please have a wonderful day.

Warmly,
Michael

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"In addition, there is another reason why I think we should favor Novick's guidelines over the guidelines of the elimination diet:

Our gastrointestinal ("GI") tract is basically a long tube of our external environment that extends through our body. Due to this:

"The human body carries about 100 trillion microorganisms in its intestines, a number ten times greater than the total number of human cells in the body." (https://en.wikipedia.org/wiki/Gut_flora)

Especially on a healthy diet, such as one following Novick's guidelines, many of these microorganisms are supportive, and aid in our digestive processes and health. We encourage their presence and number in our digestive tract through eating health-promoting foods, and these foods cause the microorganisms associated with them to thrive in our bodies, and help us more easily and effectively digest the healthy foods.

However, on the elimination diet, we artificially restrict certain health promoting foods, such as tomatoes, citrus fruits, and healthy whole grains like wheat, barley and rye. In doing so, we may begin to starve the gut bacteria that were accustomed to helping us digest these healthy foods, and they disappear from our GI tract.

Once the elimination diet is established, and all symptoms associated with the foods that were excluded disappear; primarily symptoms associated with the unhealthy foods, I would think; we then begin reintroducing the healthy foods we had restricted to determine if these are foods that our bodies can safely handle.

However, due to the absence of the healthy gut bacteria that help digest these foods, which need time to repopulate in our bodies, we will likely experience some digestive problems associated with the newly introduced healthy foods, and may misinterpret these digestive symptoms as symptoms of some disease process that is associated with consumption of the food. We would then continue to unnecessarily eliminate these healthy foods from our diet, when all we really have to do is wait for the healthy gut bacteria to gradually repopulate, and allow for easier digestion of these healthy foods.

We see the same thing when individuals increase the amount of fiber in their diet. Their gut microorganisms are not accustomed to this level of fiber, and thus gastrointestinal symptoms can result. However, so long as the higher fiber intake is sustained, the gut bacteria will gradually adapt to the higher fiber intake and the gastrointestinal symptoms should be ultimately relieved as a result.

These individuals do not have a fiber allergy, or a fiber sensitivity that demands a permanent reduction of fiber. They simply need to wait for their bodies to adjust accordingly, and then symptoms are likely to subside.

Thus, those of us who attempt an elimination diet should likely be aware of this potential phenomenon, so that we do not continue to unnecessarily exclude healthy foods from our diet because of the time needed for our gut bacteria to re-adapt to the return of these healthy foods."

[JeffN]

Hi Michael

I am going to respond and answer in a way that I hope addresses your question.

There are as many versions of the ED as there are people recommending them. And, sadly, many of them are based on “woo-hoo” theories someone has.

The problem with providing a formal template is that there is not clear cut white/black list of foods for everyone. However, what we do know is that for the majority of people, there are many foods that we have found to be the most reactive and those that are the least reactive, even though people may still react to them. So, finding the baseline of foods that are non reactive to the individual, and establishing some time on the baseline with these foods is important and may be different for each person

The elimination diet, if done correctly is not easy and it takes a lot of dedication, effort and time that many are not willing to do, so they rush the process and don't get the results they want.

Even if one was to fast first (which some consider the best way to start), this testing process must still happen as fasting doesn’t tell us which foods they will react to, it only helps us get to the baseline faster.

So, here is my approach, with 3 ways to begin...

1) Depending on the situation, one can start with a medically supervised fast. Then they can more to the ED and start with the least offenders and work forward. Regardless of whether or not one chooses to start with a fast, they still have to go through the process of the elimination diet.

2) If someone has been on a WFPB diet for years, they can either start with a medically supervised fast or they can go straight to the full on ED with the least offenders. (See below)

3) For people on the SAD, and those wanting to di this in steps, the single most important thing they need to do first, is to go on one of the “regular” WFPB programs and follow the basic general principles as just getting off of the SAD die helps many. Just getting rid of oils, dairy, animal products and highly processed foods and most sugar and salt, solves the problem for many. By doing this, one can also eliminate most all the known allergens that account for 90% of reactions. These are Milk, Eggs, Fish, Crustacean Shellfish, Tree nuts, Peanuts, Wheat, Soybeans. So, out of these 8, 4 are eliminated right away (milk, eggs, fish, shellfish) and the next, 2 are also greatly limited or eliminated (Tree nuts, peanuts, soy). And, if there is any specific food they know they react to (i.e., strawberries, oranges, etc) or suspect, they can leave those out too. The interesting thing is that when they do this, many of them will see not only their primary issue clear up but also so many other related problems will also clear up, even allergies and immune related issues. For those who want to do the elimination diet or think they need to, I also think this maybe the best first step to start with and to continue it for at least a week to several weeks to see how much "stuff" will clear up.

If they are still needing more, the next step is to eliminate wheat, gluten and soy also, and for some, corn (and sometimes seeds). Seeds often show up ground in some spice mixes. If they have not yet eliminated them, also eliminate peanuts and nuts. Continue this for another week (or few weeks).

Then, if they still need more, then we can move to the full elimination diet. By this time, it is an easier process as we have eliminated so many trigger foods.

If they are going from the typical SAD diet or other unhealthy diet, there may go through a transition period including in regard to their digestion and gut bacteria which for some, may lead to some discomfort with some gas and bloating. I have addressed how to deal with this here...

viewtopic.php?f=22&t=30907

Often, when people start this process, their immune systems are over-sensitized. They are just being bombarded with so many things and so its seems like they react to everything. After going through the first few steps, they often find may of the plant foods they thought they reacted to may be safely added back in.


My preferred version of the full elimination diet is to base each meal on one starch food and one to two vegetables. This way, if they are still having reactions, it is easier to identify the offending food as there are only 3 foods. Sometimes, they need to go down to two or even just one food for a few days. Then, once we have had a baseline of foods that dont react to for a week or two, then start the process of testing foods. One at a time from the safe food list, for up to 3 days. If in 3 days they have no reaction, then they can test the next food. If they react to a food, eliminate it, wait 4-5 days, then add another food.

I will suggest they make a list of the 20 foods they miss the most (from the acceptable foods) and then I will rank them based on which I think are the least reactive and start with those first. This way, while going through the process, at least they are adding in their favorite foods, which makes the process easier.

I had a patient in April who was so reactive, even to the list of least offenders, we went through the above process fairly quickly and they reacted to most everything and ended up on only sweet potatoes for about 30 days. They are now up to about 16 foods and still working on it but; 1) are totally amazed at how much better they feel 2) totally amazed at how many foods we regularly use and consider safe, they were reacting too. Their list now includes all winter squash, sweet potatoes, buckwheat, all beans and lentils (other the soy), carrots, peas, tahini, lemon, green beans,

Sometimes, this process happens faster and sometimes slower as so much of it is dependent on the individual and their situation.

In Health
Jeff


Elimination diet

Worst offenders
• dairy products
• eggs
• chocolate
• nuts
• shellfish
• fish
• Soy
• wheat
• corn
• citrus fruits
• tomatoes
• strawberries
• Bananas

Safest foods/Least offenders
- Starchy vegetables
• sweet potatoes
• winter squash
• Yucca

- Whole Grains
• Brown/White Rice
• Buckwheat
• Quinoa
• Millet
• Oats (certified gluten free)

- Vegetables
• Most all Cooked Vegetables

- Fruit
• most all cooked fruits
• Pears

In Health
Jeff

[MikeyG]

Thanks, Jeff.

Your response helps a great deal, and it certainly helps illustrate your recommended approach for people who believe they may have food sensitivities.

Based on your response, it appears that you have observed individuals with apparent food sensitivities find that these issues resolve without excluding these foods, as the problem is due to the overall diet and not the individual food item, especially in the case of optimally healthy plant-based foods.

Have you ever encountered individuals who identify "trigger foods" after an elimination diet who find that these foods may not be permanent triggers, and can safely be reintroduced to the diet more gradually?

As the elimination diet protocol recommends:

"For testing purposes, each "new" food should be eaten in large amounts three times a day for two days. If the food does not cause a reaction, then the dieter can conclude that this food is not a troublemaker. Most reactions occur within a few hours, but some may not show up for several days." (https://www.drmcdougall.com/misc/2014nl ... ncases.htm)

I am surprised there are not more situations where the food is causing a reaction not due to being a persistent trigger food, but because the elimination diet participant's digestive system is simply unaccustomed to the newly introduced food, especially "in large amounts."

As was noted in the link you provided, it seems that foods that are typically more difficult to digest, such as beans and cruciferous vegetables, might be erroneously excluded after an elimination diet due to their misidentification as a "trigger food" when in fact the problem may be due to the need for a gradual digestive adaptation, which should ultimately occur provided the food is kept in the diet.

I would definitely defer to your experience and expertise in diet/lifestyle, however. It is certainly comforting to think that those who end up with more limited diets after an elimination diet trial seem to be justified in their limitations, as my concern was that they might be unnecessarily excluding healthy foods, and making their diets more difficult, due to this potential pitfall.

I also thought that the food allergy desensitization work might be relevant here, as it appears many individuals with advanced food allergies, including those who require injectable epinephrine to deal with an attack, can be desensitized to the allergy over time. The research seems potentially promising for these individuals, but unfortunately seems to be focused on allowing them to eat more "normal foods," which are often less healthy products like birthday cakes, eggs, or dairy.

Oral immunotherapy appears to be able to reduce or eliminate food allergies:
- http://stanmed.stanford.edu/2014fall/i-can-eat-it.html
- http://med.stanford.edu/allergies.html

Thanks, again, for the insight and clarification. I will certainly be directing anyone who believes they have a food sensitivity to your response, for both a better understanding of their potential issue and an excellent way to address it.

Please have a fantastic day, and thanks, again, for all of your efforts.

Warmly,
Michael

[MikeyG]

Thanks, again, for your feedback about elimination diets, Jeff.

For the patient referenced below, for the 30 days when they were on sweet potatoes only, had you considered using supplements to fill in any of the nutritional holes, or did you feel that 30 days would not be long enough for issues to arise from any low values?

(Looking at 2000 calories of sweet potatoes, it appears that Selenium (3%), folate (33%) and Omega-3 (6%), are all fairly low.)

Thanks, as always, for insight. Elimination diets seem to be very worthwhile for those who benefit from them, so I thought the additional clarity might be useful for someone considering undertaking one, especially if the foods they start out with are extremely limited, like in your patient's case.

I had a patient in April who was so reactive, even to the list of least offenders, we went through the above process fairly quickly and they reacted to most everything and ended up on only sweet potatoes for about 30 days. They are now up to about 16 foods and still working on it but; 1) are totally amazed at how much better they feel 2) totally amazed at how many foods we regularly use and consider safe, they were reacting too. Their list now includes all winter squash, sweet potatoes, buckwheat, all beans and lentils (other the soy), carrots, peas, tahini, lemon, green beans,

[JeffN]

Thanks, again, for your feedback about elimination diets, Jeff.

For the patient referenced below, for the 30 days when they were on sweet potatoes only, had you considered using supplements to fill in any of the nutritional holes, or did you feel that 30 days would not be long enough for issues to arise from any low values?

Great questions.

There is no simple answer as there are so many factors involved in the answer to such a question.

Some people may do the ED because they are simply having some allergic reactions and some because of a full blow auto-immune disease. Some may be in fairly good health, some not. Some may have a fairly healthy diet, some may not. Some may be on supplements or medications (which can raise their own issues) and some may not.

This was an extreme case and while finding the baseline took almost 2 months, they were soon expanding their intake and had up to 16 foods with a variety of vegetables, fruits, beans and starches. They were also working with their traditional doctor who, on occasion ran labs, as remember, there are usually health issues driving the desire to do an ED, which the doctor may be monitoring.

The majority of those who undertake an ED are able to expand their diet after a week or two at most. Some within 3-5 days. In this case it was longer but if you re-run some numbers including adding in some of the 16 foods they got up to along the way, you will see that the diet, though limited, became quite adequate, fairly quickly.

There are some examples, some have been documented on these boards, where people had to greatly limit their foods but were able to find variety with those limited foods. When that is not possible, then yes, there may be some adjustments needed to be made, which may include supplements, etc.

However, in general, to answer your question, it is possible for a person to survive on just sweet potatoes for 30 days without hurting themselves. Remember, people fast on water alone for 30 -60 days or more. I think the longest at TrueNorth, which is very conservative, is 45 days. There are cases in the medical literature where people fasted on water alone for 6 months. And, people have lived on just potatoes for a year.

Thanks, as always, for insight. Elimination diets seem to be very worthwhile for those who benefit from them, so I thought the additional clarity might be useful for someone considering undertaking one, especially if the foods they start out with are extremely limited, like in your patient's case.

With the ED, most people who do them are highly motivated and play a very active role in the process, which is important, as most of the work (ie, food testing) is up to them. They are also usually already working with a health care professional or actively looking for one.

Unlike with fasting, there aren't places that offer inpatient supervision while someone undergoes the process. I sometimes think there should be but the problem is, this process can go only for a very long time. Even at TN, one is fasting most of the time and refeeding for a short period and it is just not possible to work out all ED food issues during that time.

Very few are able to do the ED longterm unless they are in serious pain and/or have a seriously compromised quality of life. Most actually quit in a few days, some with in a week or two.

Also, as I know the path you are on, remember, RD's are not primary (but secondary) health care providers. Except for very limited situations, we can not diagnose or interpret signs, symptoms, health conditions or even labs. I can only give you my opinion. While I know many of my licensed, credentialed and degreed colleagues, and many health coaches and chefs who are not licensed, credentialed or degreed, like to play doctor, I don't and am very clear about that in my communications, even in this forum. I encourage those I work with to be working with health care professionals, either in the WFPB world or the traditional world. While we may not like the way traditional doctors treat things, they are very good at diagnosing. As Dr Esselstyn always says, proper treatment is predicated on a proper diagnosis.

Even at the 10-day, if I see you one on one, it is under the umbrella of Dr McDougall and/or Dr Lim and have access to all your records from them and will discuss the case with them before I see you. And, after the appointment, I review anything we discussed with them and a note documenting all this is put in the medical records. This is true even if we have a consult days or weeks after you were at the program. It was the exact same way at Pritikin.

In the end, these are all choices the individual must make along with the input from a licensed, credentialed health care professional.

I hope that helps
Jeff

[MikeyG]

Thanks, Jeff. I sincerely appreciate the additional insight and clarifications.

Please have an awesome day, and thanks, as always, for all that you do.

Warmly,
Michael