Elimination Diet

The purpose of this diet is to identify hidden food allergens that may be causing some or all of your symptoms. During the elimination period, all common allergens are completely eliminated from the diet for 2–3 weeks. After your symptoms improve, foods are added back one at a time, to determine which foods have been causing symptoms.

Example of a two-week Elimination Diet Calendar

Modified from Elimination Diet handout, University of Wisconsin Integrative Medicine Department of Family Medicine

To make it easier to follow this diet, we have divided this elimination diet into two different stages. Initially eliminate foods from the first stage for 2-3 weeks and once you have determined which foods you are sensitive to, if any, eliminate them from your diet. Reintroduce the ones you did not have a reaction to and move to the second stage foods in a similar manner.

Avoid any food you know you are allergic to, even if it is allowed on this diet.

Foods you must avoid, the first stage:

Gluten and Wheat: avoiding any foods that contain wheat, spelt, Kamut, oats, rye, barley, or malt. This is the most important part of the diet. Substitute with brown rice, millet, buckwheat, quinoa, gluten-free flour products, or potatoes, tapioca, and arrowroot products.

Dairy products: milk, cheese, butter, yogurt, sour cream, cottage cheese, whey, casein, sodium caseinate, calcium caseinate, and any food containing these.

Soy: This includes soymilk, tofu, tempeh, etc.

Corn: whole corn and foods made with corn (such as corn chips, tortillas, popcorn, and bread, and other baked goods that list corn as an ingredient). Also avoid products that contain corn oil, vegetable oil from an unspecified source, corn syrup, corn sweetener, dextrose, and glucose.

Eggs: whites and yolks, and any product that contains eggs.

Nuts: Peanuts are most commonly implicated; others include walnuts, almonds, pecans, and tree nuts.

Fish and Shellfish: Shellfish including shrimp, crab, and lobster

Food additives: Avoid MSG, artificial colors, flavors, preservatives, texturing agents, artificial sweeteners, etc. Most diet sodas and other dietetic foods contain artificial ingredients and must be avoided. Grapes, prunes, and raisins that are not organically grown may contain sulfites and should be avoided.

Foods you must avoid, the second stage:

Refined sugars: Avoid table sugar and any foods that contain it, such as candy, soft drinks, pies, cake, cookies, chocolate, sweetened apple sauce, etc. Other names for sugar include sucrose, high-fructose corn syrup, corn syrup, corn sweetener, fructose, cane juice, glucose, dextrose, maltose, maltodextrin, and levulose. These must all be avoided. Some patients (depending on their suspected sensitivity to refined sugar) will be allowed 1–3 teaspoons per day of pure, unprocessed honey, maple syrup, or barley malt syrup. This will be decided on an individual basis. Patients restricted from all sugars should not eat dried fruit. Those who are not restricted from all sugars may eat unsulfured (organically grown) dried fruits sparingly. Because little is known about alternative sweeteners such as stevia, they should not be used during the elimination phase.

Fruits: Particularly citrus fruits such as oranges, grapefruits, lemons, limes, tangerines, and foods that contain citrus fruits. Other possibilities include strawberries, melons, pineapple, and other tropical fruits.

Tomatoes: Fresh and canned tomatoes and other sources of tomatoes such as sauces etc.

 Coffee, tea, chocolate, and alcohol: Avoid both caffeinated and decaffeinated coffee, as well as standard (such as Lipton) tea and decaffeinated tea. Herb teas are allowed, except those that contain citrus.

 Other:

1-  Any other food you eat 3 times a week or more: Any food you are now eating 3 times a week or more should be avoided and tested later.

2-  Tap water (including cooking water): Tap water is eliminated in cases where more extreme sensitivity is suspected. If tap water is not allowed, use spring or distilled water bottled in glass or hard plastic. Water bottled in soft (collapsible) plastic containers tends to leach plastic into the water. Bottles with the numbers 3 or 7 are likely to leach phthalates. Choose bottles and containers that are free of bisphenol A (BPA). Some water filtration systems do not take out all potential allergens. Take your water with you, including to work and to restaurants.

Read labels

Hidden allergens are frequently found in packaged foods. “Flour” usually means wheat; “vegetable oil” may mean corn oil; and casein and whey are dairy products. Make sure your vitamins are free of wheat, corn, sugar, citrus, yeast, and artificial colorings.

General Suggestions

Do not restrict calories. Start with a good breakfast, eat frequently throughout the day, and consume at least 4 glasses of water per day. If you do not eat enough, you may experience symptoms of low blood sugar, such as fatigue, irritability, headache, and rapid weight loss. Eat a wide variety of foods. Do not rely on just a few foods, because you may become allergic to foods you eat every day. To ensure adequate fiber intake, eat beans, permitted whole grains, whole fruits and vegetables, homemade vegetable soup, nuts, and seeds. Be sure to chew thoroughly, in order to enhance digestion.

Plan meals. Plan your meals for the entire week. Take some time before starting the diet, in order to develop meal plans and stock the kitchen with adequate amounts of permitted foods. For ideas, look through cookbooks that specialize in hypoallergenic diets. Most meals can be modified easily to meet the requirements of the diet, without changing the meal plan for the rest of your family. When you go to the health food store, ask for assistance in locating appropriate bread, crackers, cereals, soups, etc. Some people find it useful to prepare additional foods on the weekend, which helps to cut down on thinking and preparation time during the week. If you need further assistance or ideas, talk with your diet counselor at the office.

For people with limited access to a health food store: Searching for hypoallergenic foods on one of the Internet sites listed below can be helpful. Perform the search as an “advanced search,” with as many limitations as the site allows, such as wheat-free, corn-free, dairy-free, casein-free, and no added sugar. This type of search eliminates many of the unacceptable products, but you will still need to read the ingredients of products that interest you. You can buy directly from websites such as Glutenfreemall.com, Allergygrocer.com, and Shoporganic.com, or special-order the foods through your local grocery.

Dining out.  Do not hesitate to ask questions or make requests. For example, you could ask for fish topped with slivered almonds, cooked without added seasoning, butter, or lemon. Get baked potato with a slice of onion on top. Order steak or lamb chops with fresh vegetables also prepared without added seasonings (with the exception of garlic and plain herbs). Make sure the salad bar does not use sulfites as a preservative and bring your own dressing (oil and cider vinegar with chopped nuts/seeds and fresh herbs). Carry pure water, snacks, seasonings, etc., wherever you go, to supplement your meals, or to have something on hand if you get hungry.

Withdrawal symptoms.   About 1 in 4 patients develop mild “withdrawal” symptoms within a few days after starting the diet. Withdrawal symptoms may include fatigue, irritability, headaches, malaise, or increased hunger. These symptoms generally disappear within 2–5 days and are usually followed by an improvement in your original symptoms. If withdrawal symptoms are too uncomfortable, take buffered vitamin C (sodium ascorbate or calcium ascorbate) at a dose of 1,000 mg in tablet/capsule form or 104 teaspoons of the crystals, up to 4 times per day. Your doctor may also prescribe alkali salts (a mixture of sodium bicarbonate and potassium bicarbonate, taken as needed at a dose of 1/4 to 1/2 teaspoon dissolved in 6–8 ounces of water up to 3–4 times per day). In most cases, withdrawal symptoms are not severe and do not require treatment. When starting the elimination diet, it is best to discontinue all of the foods abruptly (“cold turkey”), rather than easing into the diet slowly.

Testing individual foods

It usually takes 2–3 weeks for symptoms to improve enough to allow you to retest foods. However, you may begin retesting sooner if you have been feeling a lot better for at least 5 days and have been on the diet for at least 10 days. If you have been on the diet for 4 weeks and feel no better, contact the office for further instructions. Most patients do improve. Some feel so much better on the diet that they decide not to test the foods. This could be a mistake. If you wait too long to retest, your allergies may “settle down” and you will not be able to provoke symptoms by food testing. As a result, you will not know which foods you are allergic to. If reintroducing certain foods causes a recurrence of symptoms, you are probably allergic to those foods.

Food sources for testing. Test pure sources of the various foods. For example, do not use pizza to test cheese, because pizza also contains wheat and possibly corn oil. Do not use bread to test wheat, because bread often contains other potential allergens. It is best to use organic foods for testing, so as not to risk interference from pesticides, hormones, or other additives that may be present in some foods.

Testing procedure.   Test one new food each day. If your main symptom is arthritic pain, test one new food every other day. Allergic reactions to test foods usually occur within 10 minutes to 12 hours after ingestion. However, joint pains may be delayed by as much as 48 hours. Eat a relatively large amount of each test food. For example, on the day you test milk, consume a large glass at breakfast, along with any of the other foods on the “permitted” list. If, after one serving, your original symptoms come back, or if you develop a headache, bloating, nausea, dizziness, or fatigue, do not eat that food again and place it on your “allergic” list. If no symptoms occur, eat the food again for lunch and dinner and watch for reactions. Even if the food is well tolerated, do not add it back into your diet until you have finished testing all of the foods. If you do experience a reaction, wait until your symptoms have improved before testing the next food. In some instances, it may not be clear whether the symptoms you are experiencing are due to the most recently eaten food or to a delayed reaction to a previously eaten food. If you are uncertain whether you have reacted to a particular food, remove it from your diet and retest it 4–5 days later. You do not have to test foods you never eat. Do not test foods you already know cause symptoms.

Foods may be tested in any order. Begin testing on a day you are feeling well. Keep a daily journal that records individual food challenges and symptoms.

Dairy tests:  Test milk and cheese on separate days. You may wish to test several cheeses on different days since some people are allergic to certain cheeses but not to others. It is usually not necessary to test yogurt, cottage cheese, or butter separately.

Wheat test: Use Wheatena (with no milk or sugar) or another pure wheat cereal. You may add soy or rice milk.

Corn test: Use fresh ears of corn or frozen corn (without sauces or preservatives).

Egg test: Test the whites and yolks on separate days, using hard-boiled eggs.

Citrus test: Test oranges, grapefruits, lemons, and limes individually on separate days. The lemon and lime can be squeezed into water. For oranges and grapefruits, use whole, fresh fruit.

Tap water and frequently eaten foods: Test tap water, if you have eliminated it. Also, test the foods you have eliminated because they were being eaten frequently.

Optional tests

If any of the items below are not now a part of your diet, or if you are committed to eliminating them from your diet, there is no need to test them. However, if you have been consuming any of these items regularly, it is a good idea to test them and find out how they affect you. Reactions to these foods and beverages may be severe in some cases. They should be tested only on days that you can afford to feel bad.

Coffee and tea: Test on separate days. Do not add milk, nondairy creamer, or sugar, but acceptable soy or rice milk may be added. If you use decaffeinated coffee, test it separately. Coffee, tea, decaffeinated coffee, and decaffeinated tea are separate tests.

Sugar: Put 4 teaspoons of cane sugar in a drink or on cereal, or mix it with another food.

Chocolate: Use 1–2 tablespoons of pure baker’s chocolate or Hershey’s cocoa powder.

Food additives: Buy a set of McCormick or French’s food dyes and colors. Put 102 teaspoons of each color in a glass. Add one teaspoon of the mixture to a glass of water and drink. If you wish, you may test each color separately.

Alcohol: Beer, wine, and hard liquor may require testing on different days, since the reactions to each may be different. Have 2 drinks per test day, but only if you can afford not to feel well that day and possibly the next day.

After the testing

After the testing is finished, please return to the office for a follow-up visit. Bring your journal with you, in order to review your experiences with the doctor.

Suggestions for self-help

Rotation diet. If you have an allergic constitution and eat the same foods every day, you may eventually become allergic to those foods. After you have discovered which foods you can eat safely, make an attempt to rotate your diet. A 4-day schedule is necessary for some highly allergic people, but most people can tolerate foods more frequently than every 4 days. You may eventually be able to tolerate allergenic foods after you have avoided them for 6–12 months. However, if you continue to eat these foods more frequently than every fourth day, the allergy may return.

Consume a wide variety of foods, not just a few favorites. If you are rotating foods, be sure to avoid all forms of the food when you are on an “off” day. For example, if you are rotating corn, avoid corn chips, corn oil, corn sweeteners, etc., except on the days you are eating corn and corn products. It is not necessary to do strict food rotation during the elimination and retesting periods.

Watch for other allergic reactions. If you have an allergic constitution, you may be allergic to foods other than those you have eliminated and tested on this diet. Pay attention to what you are eating, and review recent meals if you develop symptoms. You can then eliminate that food for 2 weeks and test it again, to see if it triggers the same symptoms.

Source: Modified from Allergy Elimination Diet section of Nutritional Medicine by Alan Gaby MD

Other resources: Food Allergy handout, University of Maryland Medical Center; Elimination Diet handout, University of Wisconsin Integrative Medicine Department of Family Medicine.