HOW NUTRITION CAN HEAL II ELIMINATION DIETS Uncovering Hidden Food Allergies and Sensitivities

HOW NUTRITION CAN HEAL II ELIMINATION DIETS Uncovering Hidden Food Allergies and Sensitivities Nancy Ann Cotter MD, FACN, FAAPMR, FABIM Clinical Associate Professor, PMR Rutgers NJ Medical School Clinical Director, Whole Health VANJ Clinical Champion, Office of Patient Centered Care

Balanced sympa/ Parasympa tone DIGESTIVE PROCESS Sympathetic overdrive 2

Balanced sympa/ Parasympa tone DIGESTIVE PROCESS Sympathetic overdrive Proper Acidity (ph 1-3) Acidity Age, PPI, antacids sympathetic tone 3

Balanced sympa/ Parasympa tone DIGESTIVE PROCESS Sympathetic overdrive Proper Acidity (ph 1-3) Healthy mucous layer Acidity Age, PPI, antacids sympathetic tone Poor mucous layer 4

Balanced sympa/ Parasympa tone DIGESTIVE PROCESS Sympathetic overdrive Proper Acidity (ph 1-3) Healthy mucous layer Intact Immune barrier Acidity Age, PPI, antacids sympathetic tone Poor mucous layer Permeability 5

Balanced sympa/ Parasympa tone DIGESTIVE PROCESS Sympathetic overdrive Proper Acidity (ph 1-3) Healthy mucous layer Intact gut-immune barrier Low bacterial growth Acidity Age, PPI, antacids sympathetic tone Poor mucous layer Permeability Bacterial growth 6

Balanced sympa/ Parasympa tone DIGESTIVE PROCESS Sympathetic overdrive Proper Acidity (ph 1-3) Healthy mucous layer Intact gut-immune barrier Low bacterial growth Microbial abundance and diversity Acidity Age, PPI, antacids sympathetic tone Poor mucous layer Permeability Bacterial growth Dysbiosis/ low diversity Regular BM Constipation/ diarrhea 8

Requirements for Autoimmunity 1. Genetic predisposition 2. Trigger 3. Intestinal permeability = leaky gut 9

Intestinal Permeability & Autoimmunity 10

The GI-mmune system Leaky Gut Tight junctions may be disrupted mechanical damage, inflammatory damage Impaired Barrier Undigested, unmodified antigens may escape surveillance Antigens may be foods, microbes etc Cross- reactivity with joint, muscle or organ tissues Autoimmunity may be precipitated

Intestinal Permeability & Autoimmunity 12

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

Food Allergy/ Intolerance/ Sensitivity Food allergy IgE Antibody- mediated reaction to a food: immediatetype 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

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

HOW DO WE ISOLATE TRIGGER FOODS?

FINDING THE NEEDLE IN THE HAYSTACK

WHAT FOODS ARE SUSPICIOUS?

A FEW Types of Elimination Diets NO JUNK SOME OF THE JUNK FREE USUAL SUSPECTS CLASSIC CLASSIC ELIMINATION ELIMINATION VERY LOW VERY LOW ANTIGENIC ANTIGENIC

UNBURDENING

ALLOWING

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

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 Frustrating if it doesn t work

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 / motivated

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

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 of sickness/ pain 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

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

Choosing the right elimination diet for your patients More complex, chronic conditions warrant more restrictive plans Addressing nutritional deficiencies Planning and preparation Record keeping

Multiple options exist for systematically 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

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