The Elimination Diet

The Elimination Diet Explained: The Facts You Need To Know

Dr. Karen D. Johnson, MD, ABOIM, IFMCP The Elimination Diet Dr. Karen D. Johnson, M.D.
Functional Medicine Doctor
Therapeutic Nutrition Expert

When to Use  | List of Foods | Plan | Symptoms | Reintroduce Foods | Supplements

An elimination diet is a process of removing certain foods from the diet in order to identify and treat food sensitivities.  These types of diets are particularly helpful for those who are struggling with non-specific symptoms like fatigue, rashes, headaches, GI issues and inflammation, as food sensitivities are often to blame for these symptoms.

What Is an Elimination Diet?

An elimination diet involves removing specific food groups for a minimum of four weeks and evaluating the improvement in symptoms. Then, you start slowly reintroducing the removed food groups over a couple of days and observe for symptoms. You can think of the elimination diet as a way of turning your body into a natural laboratory in order to identify food sensitivities. It can be more reliable than lab testing alone.

The Difference Between Food Sensitivities, Food Allergies and Food Intolerance

The difference between food sensitivities, allergies and intolerances can be confusing. After an elimination diet, many people believe they are “allergic” to certain foods, but that is not what an elimination diet tells you. What makes each of these different is the underlying cause and severity of the symptoms.

  • Food allergies are an immune reaction to food that can be immediate and severe. Imagine a child who is allergic to peanuts. Exposure to peanuts can cause them to go into anaphylactic shock and stop breathing. A food allergy is caused by IgE (Immunoglobulin E) antibody reaction to the food. This is the most severe type of reaction to food.
  • Food sensitivities are non-specific reactions caused by food that are IgG (Immunoglobulin G) mediated. Sensitivity reactions can include headache, rash, inflammation, digestive problems, and fatigue, among other things. These come from the body’s inability to tolerate certain foods. They can be difficult to identify because they can show up several days after a food has been consumed.
  • Food Intolerances are not life-threatening reactions to food, like food allergies, but can be painful and uncomfortable. Lactose intolerance is the most common food intolerance. People who are lactose intolerant don’t have the needed enzymes to digest dairy sugar, lactose, so eating it causes gas and bloating.

The elimination diet is mostly used to determine food sensitivities as they are the most elusive. Many people already know if they have an allergy or intolerance because the symptoms are very well known and easily identifiable, but they can be discovered as well.

When Is An Elimination Diet Necessary?

When Is An Elimination Diet NecessaryBeing handed an elimination diet during the first office visit might be extremely off-putting to many patients, so it’s not usually the first thing we start off with. Before deciding if a patient needs an elimination diet in the first place, we need to do an in-depth history and some lab work.

Because Functional Medicine deals with finding the clues behind root causes of illness, first time appointments can take an hour or more. We want to uncover all the facets of the current diet, lifestyle and symptoms in order to start our investigation. When you’ve hit the wall with a patient and ruled out a lot of other underlying things then it’s time to move on to the elimination diet.

The Benefits and Pitfalls Of Using Lab Testing To Find Food Sensitivities

The Benefits and Pitfalls Of Using Lab Testing To Find Food SensitivitiesIf there are lab tests to confirm food sensitivities then why do we use the elimination diet? Lab tests have pros and cons. While we do use them, the elimination diet gives us an observable test that we can direct and control. Once again, we are using the patient’s own body as a natural laboratory.

Benefits to Using Lab Testing:

The number one benefit of lab testing is time. The elimination diet takes at least 4 weeks then a few more weeks for reintroduction and observation. Some people would rather pay for lab tests to get faster results, particularly if they are in significant pain. Another benefit to lab testing is that it tests a much broader spectrum of foods, so it can pick up on rarer food sensitivities that the elimination diet could miss.

Pitfalls of Lab Testing:

Lab tests for food sensitivities are not 100% accurate. Sometimes we eliminate a food the lab test identified as a sensitivity and find that there is no improvement in symptoms. The elimination diet carefully observes your symptoms in connection to the foods you eat (and don’t eat).

Elimination Diet: Foods to Eat and Foods to Avoid

Psychologically, it’s easier for people to hear what foods they are allowed to eat, rather than be bombarded with the restrictions right away. So, let’s start there.

On the elimination diet you are still allowed to eat a variety of great tasting unprocessed foods. This is a general list for most elimination diets, but it will have to be personalized based on your individual symptoms.

Foods You Can Eat:

  • Most fruits, all organic (with the exception of some citrus, like oranges and grapefruits)
  • Healthy fats (coconut oil, olive oil, avocado, etc)
  • Nuts & Seeds (unless a nut sensitivity is suspected)
  • All organic vegetables (note: corn is considered a grain, not a vegetable)
  • Nightshades (unless you have a problem with inflammation)
  • Nut and hemp milk
  • Chicken
  • Wild caught fish
  • Rice (both white and brown are allowed)
  • Other gluten-free grains like amaranth and quinoa

Foods to Avoid:

  • All processed foods or packaged foods with many ingredients
  • Gluten and grains with gluten (even oats can be contaminated with gluten)
  • Dairy
  • Eggs
  • Shellfish
  • Soy
  • Legumes
  • Tree nuts
  • Citrus fruits (except lime and lemon)
  • Beef and Pork
  • Sugars
  • Alcohol
  • Coffee (all caffeine)

The Elimination Diet Plan

The Elimination Diet PlanThe elimination diet I use is specifically tailored to each of my patients. Sometimes we already have a general idea of what might be causing the problem so we start with a narrowed list of eliminated foods. Sometimes a patient is resistant to an overly restrictive diet so I focus first on the top 4 offenders: dairy, gluten, eggs and soy. If the patient has joint pain and inflammation, we would try eliminating nightshades (like tomatoes and eggplant) but it’s not necessary for everyone.

It’s important to note that the goal of the elimination diet isn’t weight loss. So you wouldn’t compare it to the keto diet because we are eliminating grains and gluten not carbs. You wouldn’t compare it to the paleo diet because we aren’t eating very much meat. Sometimes weight loss does occur, but it isn’t the goal we are trying to achieve.

Finally, it’s important to rotate what foods you eat. If through taking a history I discover the patient eats the same foods every single day, we may want to eliminate these foods to see if they could be the problem. A monotonic diet isn’t good for people with sensitivities.

Why Do We Avoid Sugar, Alcohol and Caffeine On The Elimination Diet?

Why Do We Avoid Sugar, Alcohol and Caffeine On The Elimination DietMost people don’t have a food sensitivity to sugar, caffeine or alcohol, so why do we remove these things from the diet when testing? In order to get accurate results, you need to remove any other stimulants from the diet. Caffeine and sugar can cause jitters, headaches and fatigue and these symptoms might get in the way of figuring out which foods are triggering an immune response. Alcohol also has unintended effects on the body and some may contain grains as well.

Many people love drinking coffee and tea, you can stick to decaf during the elimination diet. Decaffeinated green tea is the best choice.

Are Fruit Juices And Smoothies Allowed?

As long as the juice or smoothie does not contain any of the eliminated foods then there shouldn’t be a problem. I like patients to have smoothies rather than juice because the smoothie includes pulp and fiber, both of which are much healthier for your digestion.

Symptoms to Watch For On the Elimination Diet

Food sensitivities set off the immune system which affects the entire body. Many people are quick to say they aren’t having any digestive issues such as bloating or gas, and question why they are being put on an elimination diet. The gut is the barrier between the outside and your internal system. Foods you eat can go through the gut and trigger your gut associated lymphoid tissue and stimulate your immune system.

The symptoms you want to watch for include things like fatigue, rashes, headaches and general soft tissue pain. You can also have congestion from excessive mucus production, sleep disturbance and a host of other symptoms besides GI issues. In fact, it’s not uncommon for brand new symptoms to pop up during the reintroduction phase of the elimination diet.

How to Reintroduce Foods on the Elimination Diet

How to Reintroduce Foods on the Elimination DietThe most exciting part of the elimination diet is four weeks in when you finally get to reintroduce foods and take note of their effect on your body. I provide my patients with a chart to help them track their symptoms and we often start by letting them choose their favorite foods to reintroduce first. If you know prior to the diet you are sensitive to a certain food, such as gluten, it is never reintroduced.

If a person loves eggs, then we reintroduce eggs first. During reintroduction we want to challenge the immune system by eating a lot of that specific food. So you might be eating 5 eggs a day, during multiple meals, far more than you would normally eat. We want to trigger an immune response if there is going to be one.

If eating eggs gives you bad headaches or a rash then we know this might be a sensitivity. You would discontinue that food, wait for the symptoms to resolve and reintroduce eggs again be certain the reaction was due to eggs and not for some other reason. I do not want to restrict a food unnecessarily. If a similar reaction occurs, then eggs would be listed as a food sensitivity. If no reaction occurs with the second reintroduction, then eggs are not a problem.

Following this you move on to the next food group, however do not include any foods already introduced until all foods have been reintroduced even if there was no reaction. Repeat this process for each food that was eliminated. Once all foods have been reintroduced, you then have a list of food to avoid due to sensitivities and the person can resume a normal diet minus those foods.

Should You Take Supplements On The Elimination Diet?

Should You Take Supplements On The Elimination Diet?The use of supplements will be based on the individual. During the history and lab testing phase we may uncover a patient’s vitamin and mineral deficiencies. If that is the case, supplements might be recommended. The top three supplements I recommend most often to patients are Omega 3, Vitamin D and Vitamin B12.

There is a problem, however, when people are on too many supplements to begin with. Sometimes they’ve started supplement programs in the past with other physicians and never stopped taking them even though the supplements never improved the problem for which they were intended. In these cases, I will actually remove supplements from their list, if needed.

The elimination diet on its own is inherently healthy and should provide you with all the proper nutrition to keep vitamins and minerals in check.

The elimination diet should always be done under the supervision of a trained professional who can help you maintain nutritional balance and identify food sensitivities. It is best not to eliminate food groups for no reason, unless there is a suspected problem. Speak to a trained functional medicine doctor or dietitian who can guide you based on your personal symptoms and medical history.

Dr. Karen D. Johnson, MD, ABOIM, IFMCP

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