Elimination Diet

by Sue Kira, Naturopath & Clinical Nutritionist

 Introduction to the Elimination Diet

• Symptoms an Elimination Diet may support
• Benefits of an Elimination Diet
• How does an Elimination Diet work?
• How long does an Elimination Diet go for?

Which foods are removed during an Elimination Diet?

Steps to follow during an Elimination Diet

Vegan or Vegetarian Elimination Diet options

And there’s more…

Case study: Elimination Diet resolves child’s behavioural problems

Introduction to the Elimination Diet

If you have been having health issues that you think could be food related, but not quite sure which foods are the culprits, then an Elimination Diet is for you.

An elimination diet is a short-term eating plan that eliminates certain potentially reactive or inflammatory foods that may cause allergies, digestive problems, behavioural issues or immune system imbalances.

Specific foods are eliminated for a period of time, often for only a few weeks or until symptoms clear, and are then re-introduced one group at a time, noting any reactive symptoms so you know if there are any foods that don’t agree with your body.

For more information about the difference between allergies and intolerances, please read the article – Diet for Allergies & Intolerances.

Symptoms an Elimination Diet may support

You may have previously had allergy testing which may or may not have shown some reactive foods. Either way, it is not always just allergies that can cause a problem.

There are intolerances and sensitivities that may not be picked up by blood or stool testing, but an elimination diet can help you find any offending foods that aggravate your body, create inflammation, or upset your immune system.

When a food protein is ingested that isn’t well-tolerated, it can trigger a range of reactions that may cause symptoms like rashes, hives, swelling, trouble breathing, various digestive pains, and then later more severe reactions like some listed below.

Identifying and removing any sensitivities is vital to good health. When you struggle with an ongoing sensitivity, your body constantly sends out inflammatory responses to try and clear or combat the offending food matter which can create harm in many ways. Some of the conditions that can develop as a result of food sensitivities include:

• Allergies
• Arthritis
• Asthma
• Atherosclerosis
• Autoimmune disorders
• Chronic fatigue
• Cognitive decline and neuro-degenerative diseases (inc. Parkinson’s and dementia)
• Digestive system disorders like IBS (irritable bowel syndrome), bloating
• Eosinophilic esophagitis
• Inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis
• Kidney and gallbladder problems
• Leaky gut syndrome
• Learning disabilities like ADHD
• Migraine headaches
• Mood disorders, including depression and anxiety
• Muscle and joint pain, such as from arthritis
• Nutrient deficiencies
• Skin flare-ups like eczema, hives and acne
• Trouble sleeping or insomnia
• Weight gain and obesity

Benefits of an Elimination Diet

• Uncovers unknown food allergies and sensitivities
• Helps to reduce irritated gut symptoms
• Useful for healing leaky gut syndrome
• Great for auto-immune conditions
• Often provides relief for skin irritations like eczema, acne & psoriasis
• Helps disorders like ADHD, autism, anxiety and depression
• Helps clear potential causes of migraines and headaches
• Supports the immune system to heal quicker when irritating foods are eliminated

Even if you find you have no food sensitivities by the end of the program, you may still find that your body feels a lot better overall. I’ve found that sometimes, the body just needs a break from some of the eliminated foods to allow it the space to heal.

Then after the body is back in order, it can tolerate most foods, provided you don’t have too much of any of the foods you initially eliminated.

Sometimes it’s all about thresholds. Some liken it to a bucket. You start off with an empty bucket (no reactions), then as you add foods and substances into your diet that aggravate your body (alcohol, caffeine, sugar, dairy, wheat, soy etc) the bucket slowly fills up and it’s not until the bucket overflows that you feel adverse symptoms or have a health crisis.

Going back to basics by taking out as many aggravating factors as possible is like tipping out the contents of the bucket and starting again, but this time with a new awareness of the foods and substances that don’t agree with your body.

When I told my mother that, according to her symptoms, dairy was an issue for her, she replied, “But I love cheese and milk.” I said, “Yes, but does your BODY love it?” Her answer was, “No, I guess not”.

It’s about valuing our precious body over a desire to eat or drink certain things and appreciate that while our body does amazing things to try and keep us healthy, it’s not infallible, which means we must take a role to prevent illness and disease.

How does an Elimination Diet work?

Around 70-80% of our immune system resides in our digestive system as a protective mechanism against invading pathogens from what we eat. We have an intricate system where neurotransmitters (chemical messengers) from the brain and gut interact with each other.

What this means is that every time we put something in our mouth, we send signals from the gut to the brain and from the brain to the gut. These signals trigger the release of digestive enzymes, hormones and inflammatory responses as needed.

These signals also help us know when we need to eat and when we are full. It’s also how our digestive system and brain work together to communicate signs of a food intolerance, allergy, bacterial or viral infection or a nutrient deficiency.

When we eat something that triggers a warning signal our immune system and brain react by creating inflammation, giving rise to swelling, pain, tenderness and sometimes visible redness that are all a result of the body’s white blood cells attempting to protect us from foreign organisms that have entered the body.

During an elimination diet, you take away many potential sources of inflammation and aggravation so the body can have the time and space to reset any triggered responses and to heal.

Then after the inflammation has settled, you gradually introduce foods one at a time, and by feeling and monitoring the body’s responses, you discover where there is a problem food.

If the inflammatory symptoms stopped when the food was removed but then returned once the food is reintroduced, then that food should be eliminated from your diet.

How long does an Elimination Diet go for?

It’s like asking ‘How long is a piece of string’, as it depends on what you are dealing with. If you don’t have too much going on with your body apart from some bloating etc, then three weeks off potentially aggravating foods is usually long enough to allow these foods to fully clear from your body and determine if your symptoms have gone.

However, if your symptoms have improved but are still not clear from your body, then following the elimination diet for another three weeks can be beneficial, but check with your health practitioner. If your symptoms don’t change at all, then diet may not be your main issue and you need to seek advice.

Sometimes a combination of diet and other therapies such as the use of herbs, probiotics, vitamins and minerals may be needed. In other cases, certain prescribed medications along with diet can be helpful.

Most conditions that are related to food issues should be somewhat improved within six weeks, because the antibodies, which are the proteins your immune system makes when it negatively reacts to foods, take about three to six weeks to dissipate. This is usually the time needed to heal from sensitivities and to notice improvements in symptoms.

Once symptoms have cleared then it’s time for the re-challenge testing (reintroducing the foods). More to come.

Which foods are removed during an Elimination Diet?

Many foods are removed during an elimination diet. However, don’t despair, there are still many yummy foods to enjoy in the meantime.

Ten foods account for about 90% of all food-allergy reactions.

These are:

• Dairy: some react to the casein and others, the lactose
• Gluten containing foods: especially wheat
• Peanuts (legumes)
• Tree nuts
• Eggs: can be the whites or yolk
• Citrus: commonly oranges and lemons are the most reactive
• Soy products: it may be the soy or the gluten in the soy sauce
• Fish and/or seafood
• Sesame seeds
• Corn derived products

There are a range of elimination diets and most exclude the foods mentioned above, but there can be other offending foods like foods from the nightshade family, legumes, FODMAPs and high histamine foods. Other diets also exclude things like oxalates, salycilates, nitrates, brassica family foods and so on. 

For a general Elimination Diet, I suggest to exclude the foods in the list below. Before commencing, ensure that you get advice from your health care professional, as following any of these diets could lead to nutritional deficiencies if used long term. Your practitioner may suggest eliminating other foods, such as those listed in the previous paragraph.

As mentioned, if this diet does not clear your symptoms then seek professional health advice to check for other possible underlying conditions.

Foods to avoid in an Elimination Diet

• Gluten and all grains initially, including rice and corn

• Dairy & Eggs

• All sweeteners initially

• All legumes & pulses such as cashews, peanuts, soybeans, chickpeas, lentils, black, red, white, navy beans

• Onions, garlic, leeks, shallots (any of the alum family)

• Brassica foods – broccoli, cauliflower, brussel sprouts, kale, cabbage

• Nuts and seeds

• Alcohol & Caffeine

• All fruits except berries & papaya (but not strawberries, they are high risk reactive)

• Processed, packaged and fast foods

• Hydrogenated oils (liquid oils made solid)

• All food additives, food colours, preservatives and anything artificial

• Nightshade family foods such as tomato, capsicum/bell peppers, chilli, eggplant/aubergines, goji berries and potatoes

• Initially remove fermented foods like sauerkraut, coconut yoghurt and coconut water kefir and bone broths, then make these one of the first foods to reintroduce later. We initially avoid them as they are high in histamines.

Steps to follow during an Elimination Diet

• Use this diet for 3-6 weeks depending on your symptom severity, how quickly your symptoms clear, and the advice of your health practitioner.

• During this time, carefully read food labels to make sure you even avoid trace amounts of the eliminated foods. A food journal during this time is important to record how you feel. This will be very handy to monitor your progress when you begin to reintroduce foods.

• After completing the elimination phase in three weeks, or longer if needed, keep using the elimination diet and reintroduce one food group at a time. Wait for three days to see if there is any reaction to the introduced food. Record any changes in symptoms between the elimination phase and the reintroduction phase.

• For example, your symptom might be joint pains which settle a lot during the full elimination diet, but not completely because you may have joint damage. Then for example, after introducing tomatoes and capsicum/bell peppers to your salad, you notice by day three that your joint pain comes back to the level it was before the elimination. Write down the reactions (symptoms) and the cause (e.g. tomatoes, capsicum). Later you can test these foods separately in case it is only one of them.

• If you get a reaction, you need to go off that/those foods and stay with your core diet, which may be the elimination diet plus a few foods that you have tested as clear for you. Continue with this diet until your symptoms from the reactive food have gone, and then proceed to test the next food group.

• The idea is to keep introducing more foods every few days for a few days duration and if you get a reaction, break that sequence where needed. You may find that there are only a couple of reactive substances or foods and you can continue to eat everything else.

• You can then adjust your regular overall diet by excluding those reactive foods.

What order should I re-introduce foods back into my diet?

While the order of challenging (reintroducing) different foods is not critical, it is definitely best to leave the potentially worse ones till last.

These are gluten, dairy, sugar and any foods that you have been suspicious of in the past. I personally feel that gluten, dairy and sugar should not be reintroduced at all if you have any health condition, or you may find that your problems will quickly return.

The following list provides a guideline of the order of foods to reintroduce into your diet. If there are foods that you don’t normally eat because, for example, you don’t like the taste, then you don’t have to try them.

Note: never trial a food that you have previously had an anaphylactic reaction to, no matter how long it has been since the reaction. Never trial a food that you have tested allergic to, or food you think you might be allergic to. For your safety, these foods, and any other foods you get a strong reaction to, should only be challenged under medical supervision. Only reintroduce or trial foods that you had previously eaten and thought were ok for you.

Reintroduce foods in this order:

1. Probiotics, fermented foods and bone broths. These help to replenish good bacteria and help crowd out the bad bacteria in the gut. They contain organic acids that balance intestinal pH, reduce acidity and inflammation.

2. Foods such as sauerkraut are good to start with, as are bone broths as they contain collagen and the amino acids proline and glycine that can help heal your damaged intestinal walls. Gelatine made into jellies are good.

3. Once you establish that fruit is fine, you can make a coconut fruit jelly for a yummy sweet treat that will help to heal and nourish your body. 

4. Coconut products are great to introduce, as the fats in coconut are easier to digest than other fats and help to nourish a healing gut. Try coconut oil, coconut flour and coconut yoghurt or coconut kefir.

5. Fruits: start with the fruit you miss the most (that are in season)

6. Nightshade These are tomatoes, potatoes, eggplant/aubergine, capsicum/bell peppers, chilli and goji berries. A Low FODMAPs Diet includes these foods and excludes the unsuitable foods referred to earlier in this article.

7. Brassica foods: broccoli, cauliflower, brussel sprouts, kale, cabbage

8. Eggs: trial egg yolks first then whole egg (egg white is usually the worst offender of the two parts) Use pasture raised or organic where possible

9. Nuts: try almonds, pecan, macadamia, hazelnuts, brazil, pine nuts. However, for legumes like cashews or peanuts, it’s better to trial them separately.

10. Legumes/pulses: cashews, peanuts (but only if no history of problems), chickpeas, lentils, soybeans, black, red, white, navy beans.

11. Gluten free grains: rice (black, red, brown then white), corn, buckwheat, quinoa, amaranth. It is best to trial each of these separately.

12. Onions, garlic, leeks, shallots (or any of the ‘alum’ family)

13. Sweeteners like honey, maple syrup, rice bran syrup (not sugar)

If all of these above foods are fine, then you can try foods like: raw cacao treats made from the sweeteners above; cacao and creamed coconut flesh; muffins and cakes made from coconut, almond meal and eggs (depending on what foods came up reactive). 

Once you know what foods are reactive and what to leave out of your diet, your health practitioner can help you choose an ongoing diet that best suits your needs e.g. a Gluten Free Dairy Free Mediterranean Diet.

Foods that can replace gluten grains can be foods made from various nuts, seeds, and gluten-free grains.

Foods that can replace dairy products can be various nut milks (almond, hazelnut, brazil nut etc), cashew cheeses, coconut milk, coconut cream, coconut yoghurt, coconut ice-creams, coconut sour cream.

Refined sugar can be replaced with honey, maple syrup, rice bran syrup and fruits (that can be frozen and pureed to be like ice-cream). Try to limit these as they are still basically sugar and have the potential to increase inflammation in the body.

It is recommended for good health practices that you eliminate the following foods from your diet such as: processed, packaged and fast foods; hydrogenated oils (liquid oils made solid); all food additives, food colours, preservatives; and anything artificial.

 Vegan or Vegetarian Elimination Diet options

If you are vegan or vegetarian you may have noticed that you are not supposed to have legumes, grains and pulses, when testing, which makes it difficult. The best approach for a vegan or vegetarian elimination diet is to:

• Follow the above instructions

• Exclude any animal proteins (of course)

• Include the easier foods to digest like rice and lentils as your staple protein combination

• Include the vegetables and salads as advised

• When re-introducing foods back into your diet, start with the other grains and pulses (see 10 & 11 above) before other foods

• Work through the list in order of the foods you miss eating the most

• Exclude gluten grains, dairy products and sugar.

• If you are vegetarian, you can trial eggs as your first re-introduction starting with egg yolks (see 8 above)

And there’s more…

• Important: Before you commence this diet, see your medical or health care professional for qualified guidance.

• If you are not a vegan or vegetarian, ideally with your meals you should include a small amount of good quality protein from grass fed pasture raised or organic meats and poultry.

• Also include vegetables or salad and good quality oil/fats from avocados, coconut oil or olive oil. But be aware that some people react to avocado or olive oil. If in doubt, for a dressing try grape seed oil with a small amount of lemon or lime juice, or coconut vinegar, or apple cider vinegar. Also, lemon and lime can also be an issue for some, so if in doubt, leave them out.

• Seasonings such as mineral salt (Himalayan, Celtic or potassium chloride) and fresh herbs are best. But again, some people can be aggravated by pepper and spices, so it is best to leave these out until you begin to reintroduce the foods.

• The general Elimination Diet provides a selection of foods to eliminate for a core 3-6 weeks diet plan. However, there may also be something that is unique to you, and this is where your practitioner can help, as they may also suggest avoiding salycilates or oxalates for example.

• Don’t consume any foods that you have had reactions to in the past even if these foods are on the low reactive list.

• While on the Elimination Diet, it is recommended to avoid foods containing gluten, dairy and additives. These can be gradually reintroduced to gauge the effects on your body.

• An Elimination Diet is not considered a cure for various health conditions, however by including foods that support the body, and eliminating foods considered detrimental, this will help your body to do its natural job of healing.

• While on this diet, do not stop any medications or supplements previously prescribed unless advised otherwise by your medical or health care professional, who may even prescribe extra supplementation.

• During the early stages of your new diet, you may experience symptoms such as fatigue, headaches or body aches, which may occur because your body is detoxifying. However, if you are unsure about a symptom at any time, check immediately with your medical or health care professional.

Case study: Elimination diet resolves girl’s behavioural problems

Client names and identifying information changed

Little 4yr old Cassy was according to her mother Jan ‘a little shit of a kid’ (Jan’s words). Cassy was like a crazy monkey, climbing the walls, had lots of daily temper tantrums, threw things around the room, screamed for attention to get what she wanted, had bursts of energy, then slept for 20 minutes and woke up screaming and attacking again.

She would constantly pick fights with her older brother (6yrs) who was afraid of her. Jan wouldn’t even bring Cassy in to see me initially as she feared that Cassy would destroy my office. I was thankful.

Jan showed me a video of her in action so I could see what she was like. Little Cassy had dark circles under her eyes that were puffy. Apparently, she had been this way since she was a baby. She also had disgusting smelly bowel motions according to mum (I took her word for this).

Jan previously took Cassy to the doctor who suggested blood tests. That proved to be unsuccessful and traumatised Cassy, Jan and the nurse, so nothing more was done. They were referred to a behavioural psychologist, but this was unsuccessful as Cassy couldn’t settle enough for the psychologist to talk to her.

The doctor tried sedation so Cassy could settle enough to see the psychologist, but the sedatives made her unresponsive and calm but not able to listen or engage. Reducing the dose just made her level of hyperactivity increase again.

Poor Jan was beside herself with anguish for her little girl and had to resort to giving Cassy sedative anti-histamines to settle her enough to be calm at bedtime. This gave me a clue, because the anti-histamines seemed to have a positive effect on Cassy, I suggested that Cassy might have an allergy. Her eyes showed that something was not right with her immune system.

Dark puffy eyes can be a sign that the kidneys are not handling a substance in the diet, which is often gluten, dairy or food additives. So we started here and Casey was put onto an elimination diet of all of these potential reactive foods.

After only five days off the potentially reactive foods Cassy was a normal little girl. Remarkable.

She was actually much better from day two, and then gradually improved as the days went on. She didn’t need to exclude the foods for any longer than a week before we began to re-introduce foods again.

Casey asked her mother if she could have some milk. Normally I would not suggest going straight for the worst offenders, but Jan decided to go with her daughter’s instincts (or was it addiction?) and gave her the milk. Within 15 mins she was ‘crazy’ again.

So Cassy was kept off dairy for some time, until at a later date, we trialled casein and lactose separately. They were both bad for her, so dairy was completely eliminated from Cassy’s diet.

Most other foods we re-introduced were fine, but both gluten and gluten free grains gave her a tummy pain and she became angry and aggressive towards her brother. Tomatoes gave her a rash around her mouth. Sugar was fine, provided it wasn’t combined with any food colouring, or the combo had her climbing the walls again with hyperactivity.

Once sorted, Cassy and Jan were both very happy and settled and Cassy’s brother could be friends with his little sister. He kept a watchful eye on her, especially when she started school, as he knew too well the results of her reactions.

Every now and then Cassy would sneak a food she shouldn’t have, but after a while she learnt not to do this as she started to feel how it wasn’t right for her body. I saw her again when she was eight and she was amazing.

She was so smart and was telling me that she wanted to be a naturopath when she grew up.

Couldn’t she share some experiences!

Disclaimer