8 elimination diet cotter final - cdn.ymaws.com · • cross- reactivity with joint, muscle or...
TRANSCRIPT
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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