Introduction

Food allergy and/or intolerance is a common component of many chronic diseases (see Chapter 53). However, it is not readily recognized as problematic. Conventional laboratory diagnosis is not geared for testing food allergies, and most allergists dismiss the concept of delayed hypersensitivity reactions to foods (see Chapter 15). A time-honored, effective approach to both diagnosis and treatment of food sensitivities is an elimination–rotation diet. This approach has the advantage of being low cost, and the techniques must be followed assiduously to ensure clinical efficacy. Box 46-1 lists the typical indications for an elimination diet.

BOX 46-1 Indications for the Use of the Elimination Diet

• Documented or suspected food allergies and/or intolerances

• Chronic complaints that have not subsided with treatment

• Patients who have symptoms and whose tests results are all “normal”

• Patients in whom mental health problems are suspected because of lack of significant progress

• Children and teens who are labeled as having attention deficit disorder or as being hyperactive, autistic, or who have behavior problems

The Elimination Diet

The first step in the elimination diet is to remove from the diet (1) all of the most common allergenic foods—i.e., wheat and other glutinous grains, dairy products, eggs, corn, soy and tofu, peanuts, citrus fruits, yeast, and refined sugars—and (2) other often problematic substances, such as highly processed foods, chemicals, additives, preservatives, artificial colorings, flavorings, caffeine (coffee, tea, cola drinks, chocolate), and alcohol.

The object is to avoid intake of all suspect foods and substances for at least 5 days, or long enough to clear all traces of those foods from the digestive tract. The omitted foods are then reintroduced into the diet one at a time. Keeping an accurate food and symptom diary enables the offending foods to be identified and eliminated; depending on the severity of the initial test response, the foods can be carefully reintroduced into the diet within 3 to 6 months.

Although some authorities recommend eliminating only one food at a time, clinicians in this area have found that multiple allergies are the rule, not the exception. Eliminating only one allergen may not clear symptoms well enough to notice improvement. The advantages of eliminating all major allergens in the beginning are rapid clearing, minimal adverse reactions, and accurate test results. Also, when symptoms clear rapidly, the patient becomes inspired and eager to continue with the testing.

As Dr. Doris Rapp ¹ explained:

If there are several tacks in the bottom of a shoe, the whole foot hurts; removing only one tack will make little or no difference. But remove all the tacks, let the foot heal, then add back one tack at a time and the source of pain is isolated and easily identified. If only one tack (or food) is removed, no significant difference will be noted.

Variations of the elimination diet range from the most stringent plan, involving elimination of all the major allergens, refined foods, and toxic substances, to a more lenient approach, which eliminates only wheat, dairy, and refined sugars. Consideration of the patient’s lifestyle, age, weight, general health, food preferences, attitude, and family system determines the approach. For children and pregnant or lactating women, the amount of calories or carbohydrates should not be restricted; one should simply omit the major allergens.

Variations of the Elimination Diet

As can be seen in Table 46-1, all elimination and/or challenge diets are variations of this four “Rs” procedure:

1. Remove suspect foods for at least 5 days.

2. Reintroduce and/or test by challenge ingestion.

3. Record reactions.

4. Rotate foods, avoiding those shown to cause adverse reactions.

TABLE 46-1 Elimination Diet Variants

Type	Protocol
Water fast	Water-only fast for 5 days; reintroduction of foods
Dilute juice fast	Diluted fruit juice fast for 5 days; reintroduction of omitted foods
Fruit, melon, and vegetable plan	Only fruits, melons, and vegetables for 5 days; reintroduction of omitted foods
Caveman (caveperson) plan	Proteins, nuts, seeds, legumes, fruits, and vegetables for 5 days; reintroduction of omitted foods Only natural, unprocessed foods are eaten