Elimination diets

The following information is provided as general education and does not constitute personal dietary advice. Each person’s situation is different and we recommend you consult your health practitioner before making major changes to your diet, particularly if you have a significant medical condition and/or take prescription medications.

Conditions treated by elimination diets

An elimination diet is a short-term restriction in the variety of foods eaten. The core foods are those that have been found to be well tolerated by nearly all patients. A strict elimination diet is difficult to sustain and best reserved for the treatment of severe inflammatory conditions under the supervision of a health practitioner. Lesser degrees of restriction may be more suitable for those struggling with irritable bowel syndrome and suspected food intolerances. In many cases, simply adhering to a low fat, whole foods, plant-based diet will be sufficient to relieve symptoms or promote healing.

Food allergies can be life threatening and food intolerances can cause considerable discomfort. However, the publicity given to these problems has led some people to be too quick to attribute gut symptoms to food allergy or intolerance, the most obvious example being the current over-diagnosis of gluten intolerance. The alleviation of symptoms by excluding a group of foods from the diet does not always mean that these foods are the cause of the problem. For example, excluding legumes or whole wheat from the diet may relieve cramping by reducing gas production without addressing the reason why the gut has become intolerant to small amounts of gas: the real problem may be too many animal protein foods and inadequate fibre and starch intake.

Elimination diets may be used to treat:

  • Irritable bowel syndrome (IBS) – characterized by pain, bloating, diarrhea – the diagnosis is based on the symptoms and normal medical investigations
  • Coeliac disease – 100% avoidance of gluten is required
  • Inflammatory bowel disease (IBD) – including Ulcerative Colitis and Crohn’s disease
  • Rheumatoid arthritis, Lupus (SLE) and other autoimmune diseases

Low FODMAP diets have been found to be effective for treating irritable bowel syndrome. However, we consider that this may often provide symptomatic relief rather than treating the cause, particularly for those eating a typical Australian diet. This may even apply to some vegan diets that are fat-rich, fibre-poor and lacking in basic starchy foods. Restoring the healthfulness of the gut microbiome with fibre-rich starchy foods and vegetables may result in a gradual reduction in gut irritability, and permit the reintroduction of high FODMAP foods such as legumes.  An elimination diet may help to identify particular foods that trigger irritable bowel symptoms. This often made difficult by all of the other physical and psychological factors that influence IBS – a food that causes bloating and cramps one day may cause no symptoms, or just happy gas, on another day.

There is some evidence that gluten exclusion alone may not eliminate gut inflammation in coeliac disease. Some degree of elimination diet may be needed, particularly during the healing phase when the gut lining has been damaged by gluten exposure.

Ulcerative colitis, as the name suggests, is an inflammatory reaction in the lining of the colon. Pain, diarrhea and bleeding are typical symptoms and the condition can become so severe that surgical removal of part of the colon may be recommended. It would seem obvious that what’s inside the colon – partly digested food and gut microbes – to a large degree, determines the health of the colon. In keeping with this is the observation that there are populations who subsist on starchy whole plant foods who do not get ulcerative colitis or bowel cancer. Experienced clinicians and their patients report great success in treating ulcerative colitis with a modified whole food, plant-based diet, usually involving some degree of elimination diet.

Crohn’s disease is the other common inflammatory bowel disease (IBD). The pathology is different to ulcerative colitis and it can be more difficult to diagnose as it can be limited to the small intestine, too far from either end of the gut to be inspected endoscopically. It too can be a severe disease, causing pain, malabsorption and intestinal obstruction. Resection of parts of the small intestine are sometimes required. A Japanese study (Chiba et al 2010) demonstrated that a mostly plant-based diet was the most effective treatment to date for preventing relapse.

The link between rheumatoid arthritis and food/gut health is biologically plausible. Fragments of food and microbes can enter the blood stream and provoke autoimmune disease, particularly when the intestinal barrier is damaged and more permeable – leaky gut syndrome (‘increased intestinal permeability’ to medical experts). The influence of the gut microbiome on the whole immune system is an emerging area of research. Suffice it to say that the number of people ‘cured’ of rheumatoid arthritis by dietary intervention seems to be beyond what might be expected by chance alone. See our Arthritis page.

Elimination Diets

We have presented elimination diets in three tiers – from modest dietary restrictions through to a full elimination diet. The baseline, a low fat, whole foods, plant-based diet, may be enough to put many diseases into long term remission – a month of strict adherence to this baseline diet may obviate the need for an elimination diet. The ultimate elimination diet is water-only fasting – a powerful therapy that should only be used under medical supervision e.g. True North Health Center.

While a strict elimination diet followed by gradual easing of restrictions may seem logical and perhaps an imperative for those with severe disease, a more moderate approach may be easier to implement whilst continuing one’s usual life.

Protocol for a mildly restricted elimination diet:

  • This is a whole foods plant based diet with no oil, dairy or other animal protein foods
  • Avoid coffee and other caffeinated drinks
  • Avoid yeast products, including nutritional yeast (especially those with Crohn’s disease, but could also be appropriate for other autoimmune diseases)
  • Eat more starches (brown rice, rolled oats, wholegrain pasta, potatoes)
  • Reduce, but not eliminate FODMAPs
  • Eat only moderate quantities of fruit
  • Eat more vegetables cooked rather than raw
  • Beverages – avoid alcohol, soft drink and juices, drink plenty of water (6-8 glasses per day)

Protocol for a moderately restricted elimination diet:

In addition to above –

  • Eat plenty of starch, but avoid gluten containing grains (wheat, barley, rye)
  • Minimize high FODMAP foods, including legumes
  • Limit fruit to 2 serves per day of low FODMAP non-citrus fruits
  • Avoid nuts and soy products
  • Cook most vegetables
  • Beverages – drink plenty of water (6-8 glasses per day)

Protocol for a strict elimination diet, eliminate all foods except:

  • Brown rice
  • Cooked sweet potatoes (white potatoes can be included if well tolerated but avoid green and sprouted areas)
  • Pumpkin
  • Cooked green and yellow vegetables (avoid tomatoes)
  • Cooked fruit (avoid citrus)
  • Avoid all condiments, use a little salt if necessary
  • Drink plenty of water (6-8 glasses).

NB There are no universally ‘safe’ foods – if symptoms are not alleviated on a strict elimination diet try cutting down to just one starchy food for a few days at a time. We have heard of people even reacting to sweet potatoes or rice.

After one to two weeks eating this way your symptoms should have gone or at least eased. Add one food back in at a time (in a sizeable quantity) and give it a day or two before trying each new food. Do not introduce two new foods at once. If you have a reaction to a food, wait several days before trying another new food. Consider starting a course of probiotics once symptoms have eased (take with food).

Expanding food options (one at a time):

  • Small amounts of raw vegetables (introduce raw cruciferous last)
  • 1-2 servings fruit (introduce citrus last)
  • Non-gluten containing grains, e.g. buckwheat, quinoa, millet, oats
  • Lentils – start with ¼ cup, then other legumes in small amounts
  • Tempeh

It can take time to heal a severely inflamed gut, and some individuals may have long term problems with some foods (e.g. wheat), but in general you can expect to enjoy a wide variety of whole plant foods once healed. Reactions to particular foods can be unpredictable – a food that causes bloating one day may be tolerated on another occasion.

Even when an intolerance is determined, one may decide that the enjoyment (“pleasure” in Doug Lisle’s Motivational Triad) that the item brings (think delicious fruit or coffee) outweighs the expected discomfort (“pain”) that will likely follow.

See related pages:

Resources

Peer reviewed articles

Page created 23 June 2017
Page last updated 21 September 2017