Appendix 4 Elimination diet for rheumatoid arthritis

Transcription

1 Appendix 4 Elimination diet for rheumatoid arthritis Elimination diet for rheumatoid arthritis 237 This is the diet used by Dr Gail Darlington and colleagues in their study published in The Lancet {Darlington LG, Ramsey NW, Mansfield JR (1986): Placebocontrolled, blind study of dietary manipulation therapy in rheumatoid arthritis. The Lancet 1(8475), ; see section 7.2}. However, Dr Darlington (pers. comm., 2005) comments: Many patients find it very difficult to comply with the diet at this level of strictness in the elimination phase. For the past five years or so, I have permitted really rare fruits and vegetables such as sweet potatoes, papaya, mango, papaw and kiwi fruit in the elimination phase which aids compliance and at the same time makes it easier for patients to hold their weight. I am not aware of any loss of efficacy as a result of this minor level of leniency although I cannot back up that statement with scientific data. The diet was later retyped into the format below and used by Dr Dorothy Pattison when she was Senior Dietician with St Albans and Hemel Hempstead NHS Trust, , mainly, but not exclusively with RA patients. Undertaking the diet regimen was the patient s decision and agreed by the rheumatologist. Dr Pattison (pers. comm., 2005) reported: A small number of patients (approximately 6%) identified foods that aggravated symptoms but other positive outcomes were weight loss (when overweight though surprisingly few patients experienced unwanted weight loss), improved eating habits and improved feeling of wellbeing. Though these are not particularly robust measures, they were important to the patients. There were plenty of people who could not follow the regime, but at least they had given it a try. Dr Darlington (pers. comm., 2005) comments: The diet sheet you quote for the dietary elimination and reintroduction of foods is at a level of strictness which I used originally, to be a complete purist in our original research studies. The diet Stage 1 For seven days starting on (date).your diet will be totally restricted to:

2 238 Elimination diet for rheumatoid arthritis Trout, salmon, cod either grilled, roasted, hot or cold Pears (fresh) which can be eaten raw or baked or boiled but with no additions Carrots (fresh or frozen) raw or boiled in mineral water Mineral water still or sparkling spring water (no additions) Use only sea salt NB Pear juice can be made by removing the skin from pears and liquidising them with spring water. Optional On the first day of the diet, in the morning, three teaspoons of Epsom salts in half a pint of warm water may be taken to eliminate previous foods from the bowel. If constipation occurs later in the seven days, a further dose may be given. It is vital to the whole investigation that there is absolutely no break in this diet. A small sip of coffee, for example, in those seven days could completely change the pattern of response that is crucial for detecting an adverse reaction to a specific food. As well as restricting your diet, it is very important NOT TO SMOKE. It is very possible that initially you will feel worse than usual, especially in the first three days. Keep a comprehensive record of all symptoms you notice on each day of this restricted diet, for example, headaches, tiredness, dizziness, aching muscles, catarrh, joint swelling and other such symptoms. Medications almost always include food substances. Wheat, corn, potato and yeast are used as base materials or fillers in a wide range of tablets. Try and avoid using medications for symptom relief or keep the use of these to a minimum. DO NOT ALTER YOUR MEDICATION FOR ARTHRITIS WITHOUT FIRST DISCUSSING THIS WITH YOUR CONSULTANT RHEUMATOLOGIST. Stage II The first four foods to be assessed in Stage II are broccoli, runner beans (fresh or frozen), pineapple (fresh) and turkey (fresh). It is worthwhile buying these foods in advance, so that they are ready for use after your seventh day consultation with your dietitian. These foods will be introduced one at a time in the second stage, followed by many others as the week goes on. The main aim in stage II is to obtain a list of about 20 foods that do not cause you to have an adverse reaction. By the end of Stage II you should have a reasonable range of safe foods to eat while you are testing further foodstuffs. These initial foods have a relatively small risk of producing a reaction but no food is completely safe. A suggested order of introduction is given below. It is advisable to keep rigidly to this as the order has been arranged for two specific reasons. Firstly to ensure that the safest foods are introduced first and secondly to ensure that new foods are tested in such a way that members of similar food families are separated by four days. This avoids the possibility of false-negative responses from cross-reaction within the food family.

3 Elimination diet for rheumatoid arthritis 239 Stick to the foods that have been suggested for each day but these foods can be tested in any order on that particular day. Once a food has been tested and found to be safe it can be included in any subsequent meal. It is a cumulative process with each meal usually consisting of the new food to be tested plus any foods already found to be safe. When testing a food, the most important feature to watch for is the recurrence of symptoms. Symptoms would normally occur within five hours of eating a sensitive food. Therefore, if one food is introduced at breakfast time, e.g. 8am and no adverse response occurs by 1pm, then it is usually safe to introduce another food at approximately 1pm. Similarly, if no response occurs to the lunchtime food by 6pm, it is usually safe to try a further new food then. Never introduce two new foods at the same time as it will be impossible to tell which food is causing an adverse reaction if one does occur. Symptoms can vary from person to person, e.g. one person may develop a headache while someone else may have increased joint pain or swelling and others just might feel lethargic or depressed. Reactions may also vary in intensity. There is usually little doubt about strong reactions but mild reactions can be difficult to be certain of. If you are uncertain, a reaction can be confirmed or rejected by retesting a food at a later stage. There are two major rules on food testing: (1) If in doubt about a food reaction leave the food out of the diet. (2) Never re-test a food in less than five days from the original test. Important notes: if an adverse reaction does occur and symptoms return, then no further testing should be done until symptoms clear. To assess whether a food reaction has occurred or not you must be quite sure about what symptoms occurred when the new food was tried. If an adverse reaction does occur then you must restrict yourself to only the foods that have been tested and found to be safe until symptoms clear. This may take between 1 and 3 days. Remember to keep a strict food and symptom diary to record what you eat and if any reactions occur. Stage II: list of foods Day Date Food Comments 7 Broccoli or frozen 8 Runner beans or frozen Pineapple Turkey or frozen, whole or pieces

4 240 Elimination diet for rheumatoid arthritis Day Date Food Comments 9 Tomatoes Melon Beef or frozen 10 Tap water Rice Brown, boiled Lettuce 11 Banana Soya beans Grapes This is an important test as soya is present in many processed foods. Soya beans are available in supermarkets and health food shops. Soak the beans first and cook according to instructions on packet Red or green 12 Cows milk Any variety 2 large glasses Cabbage Chicken or frozen whole or pieces 13 Indian tea With milk if it is safe Apple Yeast Take two teaspoons of baker s yeast or brewer s yeast powder (raw or dried). This can be quite an unpleasant taste so have some safe food with it. Again this is an important test because of the wide range of products that contain yeast Can be bought from health food shops and supermarkets 14 Butter Do not do this test if the milk test was positive Leeks Pork, boiled, baked or cooked in butter if safe Roast pork or pork chops grilled, roast 15 Lamb or frozen Plaice or frozen (no breadcrumbs)

5 Elimination diet for rheumatoid arthritis 241 Stage III The next stage involves testing the major, staple foods, therefore it is very important that you test them carefully. A maximum of two foods per day is suggested. WHEAT and CORN are absorbed more slowly. They frequently have a delayed or muted response. Therefore, these foods are tested for two full days each. Stage III: list of foods Day Date Food (morning) Food (evening) 1 Eggs not fried in oil Potatoes not fried in oil 2 and 3 Wheat as wholemeal bread IF yeast test is negative Use homemade bread or from a bakery in order to reduce the level of additives. Alternatively, use pure wheat flakes or wholewheat macaroni (plain and boiled) You must test wheat at every meal for the next two days 4 Percolated coffee (coffee beans) Mushrooms 5 Cane sugar (demerara) 6 Oranges Black pepper 7 Beet sugar (white) Bacon IF pork test negative 8 and 9 Corn test. Using corn on the cob or glucose powder. Use at least two dessertspoons of glucose powder or fresh corn on the cob at every meal for two days 10 Onion Natural peanuts (in the shell) 11 Cheddar cheese (if other dairy Spinach products test negative)

6 242 Elimination diet for rheumatoid arthritis Stage IV Stage IV: list of foods Day Date Food Comments 1 White bread IF yeast and wheat tests negative Garlic 2 Peas or frozen (NOT petit pois) Grapefruit Dates Natural (try health food shop) 3 Cucumber Celery Cauliflower or frozen 4 and 5 Rye bread this is a two-day test. IF the yeast test was positive, use yeast-free rye based alternative, e.g. Ryvita. If using bread, try homemade or from a bakery as before 6 Tuna fish tuna steak in most supermarkets or fishmongers *Rhubarb *Honey Natural, clear 7 *Instant coffee this is a chemical test. Look for a coffee without corn added. Do not test if you reacted to ordinary coffee. Asparagus Lemon 8 *Olive oil

7 Elimination diet for rheumatoid arthritis 243 Day Date Food Comments Lentils *Tinned carrots do not test if you reacted to fresh carrots. This is a test for the phenolic resin lining of the tin. Check that the tin says no sugar added 9 and 10 Oats e.g. porridge oats. Take at every meal for two days 11 *Monosodium glutamate this is a flavour enhancer used in many processed foods. Can be obtained from some supermarkets and Chinese supermarkets. To test, sprinkle on top of some meat. *Prawns or shrimps *Brussels sprouts 12 *Saccharin tablets *Herrings *Almonds 13 Malt extract at every meal for 1 day (in supermarket or health food shop) 14 Avocado pear Green or red peppers Raisins 15 Chocolate contains wheat, corn and sugar. Do not test if any of these caused a reaction Spice mixture

8 244 Elimination diet for rheumatoid arthritis Food items marked with an asterisk* are unrelated to other items and can be interchanged as long as the spacing between other foods is undisturbed. Food dyes, emulsifiers and other additives have not been specifically assessed but when standard foods have been evaluated reactions to such chemicals are usually obvious. Seasonal fruits such as cherries, plums, apricots, peaches, strawberries, raspberries, gooseberries and blackcurrants have not been included but should be tested during their season. You have at this point assessed more than 60 different food items, which account for at least 95% of what most people eat.