Managing Food Intolerance Through Elimination Diets

  • Harry White Master of Science - MS, Biology/Biological Sciences, General, University of Bristol, UK
  • Polly Gitz Bsc Nutrition Student, University of Leeds

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Introduction

If you regularly experience adverse reactions to certain foods or food groups, such as tummy troubles, bloating, headaches, or fatigue, you may have a food intolerance. An intolerance is different from an allergy. An allergy occurs when your body’s immune system overreacts to an otherwise harmless substance and can be life-threatening in severe cases. Intolerances are not related to an immune response. 

However, food intolerances are non-fatal. Diagnosing a food intolerance and identifying the culprit can be challenging. Fortunately, it is possible to do so at home through the elimination diet. 

The elimination diet is an effective and useful tool for mitigating symptoms related to food intolerances, and anyone can do it. This article will discuss how to implement the diet and its limitations.

Understanding food intolerances

Intolerances vary significantly depending on the foods that trigger them and the underlying cause. A common intolerance is lactose intolerance, a protein found in milk and other dairy products. An enzyme called lactase is required to digest it. Many people have a lactase deficiency and thus can’t process the lactose, leading to adverse reactions when consuming dairy.1

Other underlying causes include chemical sensitivity, gluten sensitivity, and gastrointestinal disorders. Unfortunately, no single test can diagnose an intolerance; however, it can still be identified through a process of elimination, the principle that underlines the elimination diet. 

The elimination diet

In theory, the elimination diet is simple enough; you remove multiple food groups likely to trigger an intolerance, e.g., dairy, for a while and monitor symptoms to see if they go away. Then, individually reintroduce these food groups. If symptoms return after a certain food group is reintroduced, you’ve likely identified what you’re intolerant to. Below, we outline the multistep approach to the elimination diet.

  1. Consult a healthcare professional. Before starting, book an appointment with a healthcare professional. They can assess whether an intolerance and not something else causes your symptoms. They can also advise on nutrition balance and help you design the diet to fit your dietary needs, as it is important not to impose unnecessary restrictions.
  2. Identify suspected food groups. Common intolerances include soy, nuts, dairy, gluten, and eggs. Carefully consider which food groups to eliminate.
  3. Elimination. Remove all suspected food groups from your diet for up to 6 weeks. This allows time for your body to flush out any substances you’re intolerant to and for symptoms to subside. The length of this step will vary by individual, the aim is to totally or significantly reduce symptoms.
  4. Keep a food diary. It is important to keep a detailed record of your diet and what you eat on a daily basis. A meal planner or food diary is recommended. You can also record other factors, such as stress and sleep, as these can also influence intolerances. 
  5. Reintroduction. Reintroduce food and food groups individually, one at a time. Reintroduce a food group and monitor symptoms for a few days before reintroducing the next food group. This is the step that will hopefully let you identify what foods you are intolerant to.2
  6. Maintenance. Finally, once the exact intolerance has been identified, you can permanently avoid or eliminate the culprit food group and permanently reintroduce safe foods to help maintain nutritional balance and variety. 

Efficacy of the elimination diet

The efficacy of elimination diets has been proven in multiple instances to reduce symptoms associated with food intolerances. 

There is evidence that it can help to mitigate the symptoms of irritable bowel syndrome (IBS). Participants in a study investigating elimination diets as a treatment for IBS reported improved symptoms, such as reductions in bloating and abdominal pain and an associated quality of life improvement.3

Elimination diets have also been studied as a treatment option for non-celiac gluten intolerance. In many cases gluten intolerance is incorrectly self-diagnosed, leading to unnecessary dietary restrictions. Elimination and subsequent controlled reintroduction of gluten from a person's diet can help identify whether they have a genuine intolerance, or whether their symptoms have a different origin.4 A precise diagnosis is vital for effective treatment.

Elimination diets have also been shown to be effective in identifying multiple food intolerances. In patients with complex symptoms or a wide variety of symptoms, the elimination, reintroduction, and documentation process provides a useful framework to systematically identify triggers with precision.5

Safety considerations and challenges

While simple in theory, in practice elimination diets can be challenging and there are some safety implications to consider.

Nutritional balance: If we take all of the more common and likely triggers, eggs, dairy, soy, gluten, and nuts, they encompass a large proportion of a typical diet. If you were to eliminate them all at once without adequate planning, you could expose yourself to certain dietary deficiencies, which may have their own associated symptoms, making it very difficult to identify the triggers of your intolerance. 

For example, many people rely on dairy as a source of calcium and vitamin D. If they were to eliminate dairy from their diet, it would be important to ensure they have an adequate replacement.6 A health care professional can help advise on dietary considerations when approaching an elimination diet.

Duration and compliance: Complying with dietary restrictions can be difficult, however, for the elimination diet to be effective, it must be followed strictly. Practically, this can make life inconvenient, you have to be rigorous in checking the ingredients of pre-packaged foods, and if you wish to eat out or have someone cook for you, ensure they are able to accommodate your diet. 

Fortunately, the elimination step is temporary, and the incentive that this may help mitigate symptoms in the long term should hopefully be a strong motivator.

Psychological impact: Restrictions in diet have been associated with negative effects on mental health. For many, food is a simple daily pleasure and comfort, and sudden restrictions may take some getting used to. It can also make taking part in social activities that involve food difficult, leading to feelings of social isolation. It is always okay to ask for help if you are struggling with the diet and healthcare professionals can provide support, practical advice, and mitigation strategies to help you finish the diet.7

If you are struggling, it is important not to worry and remember that difficulty adhering to a diet is very common and in many cases it is expected.

Reintroduction: Reintroduction has to be done carefully and patiently. It is important not to reintroduce foods too quickly, and to continue carefully monitoring your diet and symptoms. If you reintroduce two foods too close together, it can be difficult to determine which one contributed to the return of symptoms. This increases the risk of incorrect conclusions and long-term dissatisfaction with the results of the diet. 

Role of healthcare professionals

It is highly recommended that you consult a healthcare professional before starting an elimination diet. If necessary, depending on the nature of your intolerance, a specialist such as a gastroenterologist can also provide assistance. 

Initial assessment: They can assess your medical history, symptoms, and dietary needs, and be best placed to advise you on the likely triggers of your intolerance, and thus what foods to eliminate. 

Dietary planning: They can advise on whether your proposed diet is nutritionally balanced and on any potential deficiencies. Everyone's elimination diet will look slightly different, with no one-size-fits-all approach. Thus it is important to tailor your diet to your specific needs, something a healthcare professional can advise on.

Monitoring and support: They can also advise on the intricacies and best practices for recording your diet and monitoring your symptoms. If symptoms become worse, or new symptoms develop, you should consult a healthcare professional and consider reassessing the diet strategy.

Reintroduction guidance: This is a vital step, and if rushed, you can undo all the hard work you put into the elimination phase. A healthcare professional can help you structure this step and accurately identify triggers

Conclusion

Food intolerances can negatively affect your quality of life, they have a wide variety of underlying causes and can present in an equally wide variety of symptoms. This can lead to frustration as it can be difficult to diagnose and identify the culprit foods that trigger your symptoms. 

However, elimination diets provide a solution and are a useful way of identifying potential food intolerances. Eliminating likely triggers and carefully reintroducing them individually allows you to accurately assess which foods or food groups are causing your symptoms.

They require careful planning and meticulous adherence for success. This can be challenging and the extreme nature of the diet presents certain nutritional and safety concerns. However, with dedication and the guidance of a healthcare professional, the elimination diet can be an effective and safe way to identify and manage food intolerances, leading to long-term quality of life improvements.

References

  1. Vighi G, Marcucci F, Sensi L, Di Cara G, Frati F. Allergy and the gastrointestinal system. Clin Exp Immunol. 2008 Sep;153 Suppl 1(Suppl 1):3–6.
  2. Abrams EM, Sicherer SH. Diagnosis and management of food allergy. CMAJ [Internet]. 2016 Oct 18 [cited 2024 Jun 21];188(15):1087–93. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5056872/
  3. Gibson PR, Shepherd SJ. Evidence‐based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J of Gastro and Hepatol [Internet]. 2010 Feb [cited 2024 Jun 21];25(2):252–8. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1746.2009.06149.x
  4. Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, Gibson PR. No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology. 2013 Aug;145(2):320-328.e1-3.
  5. Sicherer SH, Sampson HA. Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment. J Allergy Clin Immunol. 2014 Feb;133(2):291–307; quiz 308.
  6. Venter C, Brown T, Shah N, Walsh J, Fox AT. Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy - a UK primary care practical guide. Clin Transl Allergy. 2013 Jul 8;3(1):23.
  7. Muraro A, Werfel T, Hoffmann-Sommergruber K, Roberts G, Beyer K, Bindslev-Jensen C, et al. EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy. 2014 Aug;69(8):1008–25.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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