Great Smokies Medical Center of Asheville

Elimination/Challenge Diagnostic Diet

Read this information in its entirety before starting your elimination/challenge diagnostic diet.

CAUTION: Never do elimination/challenge testing on a food to which you have known or suspected life-threatening (anaphylactic) reactions. Persons with potentially life threatening conditions such as severe depression, severe asthma, seizures, extremely high blood pressure, heart arrhythmias or other symptoms of a severe nature are not candidates for this at-home method of testing without medical supervision. The symptoms provoked on this diet may be more severe and dramatic than those experienced on an everyday chronic basis.

There is a very accurate, revealing, and inexpensive method of determining what, if any, foods may be contributing to your health problems. This method, called elimination/ challenge testing, can be carried out in your own home.

This method is suitable for infants, children, and adults. School aged children do pose some special problems due to possible food swapping, shared treats, an inability to determine exactly what is in school cafeteria food, and general lack of parental control over their diet. School vacations may be the best time to test school aged children. You will then be able to monitor your child’s diet and help your child cope with what may be strong cravings for the foods that are eliminated from their diet. This craving may lead to sneaking of foods, and eating even small amounts of the food being tested can invalidate the results of the food challenge test. Women who experience numerous symptoms prior to or during their menstrual cycle should not use that time of the month as their time for doing this diagnostic dietary testing. The pre-existence of numerous symptoms and the hormonal influences make the results of testing difficult to interpret, at best.

It may be understandably difficult to buy into avoidance of foods based on seemingly abstract results of numbers on a laboratory report, especially if they have no apparent relevance in the everyday life of the person. Such blood testing gives clues to what foods are problematic, but the elimination/challenge diagnostic diet goes one step further by informing the person what specific impact a particular food has on their health. Persons who have positive reactions to food allergy testing by either skin testing or blood testing at the Medical Center may need to verify that a particular food is a cause of their symptoms by using the food elimination/challenge diagnostic diet. If done properly, this method is as accurate and probably more revealing than the food testing by any other method. The American Academy of Environmental Medicine calls it the gold standard of food allergy diagnosis.

The disadvantages of the elimination/challenge method are: 1) It requires more effort of the patient, 2) it requires more time to get results, 3) its usefulness requires strict adherence to the techniques described below, and 4) as with all methods of food allergy testing, a false negative reaction can occur to foods if they have not been eaten for a long time.

Many allergies are obvious to the sufferer. Pollen, dust, and danders often produce allergic symptoms immediately and seldom is the sufferer left in the dark as to what is causing their symptoms. The basis of the effectiveness of the elimination/challenge diagnostic diet is the fact that most food allergy is hidden or masked because most symptoms of food allergy are delayed in onset. This means you can eat a food Monday and not react to it until Tuesday or Wednesday. If you frequently eat a food to which you have a hidden allergy, for example wheat (toast for breakfast, a sandwich for lunch, and pasta for dinner), you can end up with chronic symptoms and be genuinely clueless as to the cause. The techniques outlined here can unmask the previously hidden reaction, exposing the true cause and effect relationship one has with a particular food.

The elimination/challenge diagnostic diet consists of five days of strict avoidance of the foods you intend to test, and then systematic reintroduction of foods one at a time in the method described in detail below in steps 1-10.

1) Choose a start time when it will be easiest for you to have a restricted diet-Thanksgiving Day dinner with family may be the wrong time. As you may experience withdrawal symptoms such as irritability, cravings, headaches, etc., coordinate the timing of your diet with your work schedule and other expectations on you or your child.

2) Purchase a spiral bound notebook to use to keep a written record of symptoms, not forgetting ones that are so chronic that you have almost accepted them as “normal”. These include such symptoms as spaciness, headache, stiff neck, throat clearing, shortness of breath, coughing, fatigue, aches and pains, depression, weakness, increased sleep need, fluid retention, irritability, urinary tract symptoms, skin rashes, etc. Write down when you feel well, also. Keep this diary after you are finished with your testing-food allergies can persist over a lifetime, and that information could prove invaluable later in life. Be as observant as a crime scene investigator, and work from the premise that everything is caused by something, even when the cause isn’t apparent. This mindset will help your efforts pay off in better health for you. The opposite belief has led to many medical conditions being described as having “no known cause”. It is common for all of us to infer emotional causation especially for behavioral problems in children or mood disorders in adults. Open your mind to the possibility that these symptoms may have physical triggers. If your child goes from playing quietly to “climbing the walls”, being irritable, or needing an unscheduled nap, that is a symptom. Write it down and the patterns of symptoms will become your “crime scene investigation” notes to review later. If the child being tested is old enough to understand, set this testing up as an experiment in which he/she can play an active part.

3) Decide, with your physician if need be, which foods are to be tested. Exposure to these foods is required in the days prior to the elimination phase, so be sure to include this food in moderate amounts daily prior to starting the elimination of it from your diet. For people who have not already manipulated their diet, this simply means eating as they usually do.

4) Plan ahead now to have foods on hand to eat that you are not eliminating during the elimination phase. These are typically less commonly eaten foods that are not usually eaten on a daily basis. It only makes sense to also eliminate all foods with sugar, preservatives, artificial colors, and flavors that can themselves cause symptoms. Read labels! You will more likely avoid accidentally eating some form of the food being eliminated by eating food prepared at home. Cook with fresh unprocessed ingredients. Labeling of processed foods, though improved in recent years can, legally, omit foods of the label that are actually in the prepared food. And labels can be vague-for instance “vegetable oil” may be corn, soy, peanut, safflower, coconut, palm, or sunflower in origin.

5) During the elimination phase, eliminate all sources of the food(s) to be tested for five days. It is more efficient to eliminate a group of five or so foods all at the same time, although you need to test the foods individually during the challenge phase. Do not fast for the five days. Fasting creates a stress that you don’t need during this time. You may feel worse the first one to three days of going without a habitually eaten food due to occurrence of withdrawal symptoms. If you or your child feels worse during the elimination phase, you can try using the Vitamin C and Alka Seltzer Gold as described at the end of this paper for symptomatic relief, but do not take either on the morning of your challenge meal. If you make a mistake and eat the food to be tested during this five-day elimination period, you will need to restart the five-day elimination phase again. Continue to record all foods eaten and symptoms experienced. If your or your child’s target organ for allergic reactions is their brain, you may need to stop and remember that being angry or impatient with yourself or anyone else for having a “brain allergy” makes as much sense as being angry with arthritic symptoms of someone who has their joints as their target organ. There is just a different target organ involved. It needs to be said here that most often five days of elimination is adequate to unmask food allergy. Much less often, however, up to two weeks of elimination will be required to rid the body of the effects of the food in question. This seems to be more apt to be true with pediatric behavior disorders, depression in adults, sinusitis, and arthritis. If you do feel you are not “cleared” of the effects of the foods being eliminated in five days, you cannot go wrong by continuing the elimination phase for a few days longer, up to two weeks at the most.

6) Many people with allergies do not feel well when they wake up. If this describes you, you should postpone the eating of your test meal until your morning symptoms clear. On the morning of the day your challenge phase starts, eat only the chosen food being tested in its purest form in 2-4 times the quantity normally eaten at a meal. If you are testing wheat, eat cream of wheat cereal or whole organic wheat berries cooked in water (not milk) instead of using bread as your test meal. Bread contains yeast, vegetable oils, and many ingredients in addition to wheat. Use a glass of plain cow’s milk to test cow’s milk. To test chocolate, use a bar of unsweetened baking chocolate, not your favorite chocolate bar that contains maybe a dozen other ingredients. To test corn, fresh corn on the cob (no butter), or freshly dry popped popcorn is acceptable. If possible, eat organic foods for your test meal and you will rule out any adverse reaction to traces of pesticides that themselves are capable of provoking symptoms. Eat the purest form of the food you can obtain.

7) After eating your test meal, observe yourself for two hours for any changes, not forgetting to observe for changes in mood such as becoming irritable or feelings of hopelessness. Keep in mind that someone else may be more objective in observing you than you are. Eat no other foods during this time. You may drink water. If, after the first two hours of observation you notice no change or a vague change that you are not certain of, repeat your test meal and observe yourself for an additional hour. If no changes are noted by the end of this hour, resume your normal elimination diet, add the single food being tested back into the diet in normal quantities, and continue observing for symptoms for 24-48 hours for a possible delayed reaction. Remember unlike dust or pollen, most food allergies are delayed, making their detection challenging. Continue to record your responses in your food diary. If you have no reaction after 48 hours, consider the food to be non-reactive. For unknown reasons, reactions can occur to the food challenge, which are distinct, but different from those caused by that food when it is eaten on a daily basis. For example, a potato challenge meal could make you extremely sleepy, but in everyday eating may cause joint pain. Any symptoms, familiar to you or not, indicate a positive reaction.

8) Continue testing each of the foods you have eliminated in the same systematic way described above, one at a time. You should clear the reactions, if any, to the prior food test before testing another food. (See recommendations below for clearing an adverse reaction to food.) You may be able to test two foods in the same day, or you may only be able to do one every two days, depending on your reactions.

9) At this time, your physician may determine, based on your reactions, if you need to eliminate the reactive foods or rotate them on a schedule, usually every four days. Generally speaking, elimination or avoidance of foods that caused more problematic symptoms is required, and four-day rotation of less reactive foods is advised. Some food allergies are fixed, meaning that no matter how long you avoid or rotate them, you will always react. Other food allergies are concomitant and will react seasonally with some apparent synergistic or cross-reactivity, often associated with pollen exposure. Most food allergies however, are dose and frequency related, and after a period of time of avoidance or rotation, you may find a frequency and dose of eating that food that you can tolerate. If you resume the same dose and frequency of eating it as you did prior to the testing, you can expect previously experienced symptoms to return.

10) If you experience symptoms from eating your challenge test food, the crime scene investigator in you may wish to observe your reactions to see what unfolds. However, if you are certain that you have had a reaction to a food or are quite uncomfortable with your symptoms, there are some actions you can take to decrease the amount of time you feel uncomfortable.

Some people will get loose stools from Vitamin C at very low doses and others not at all. Or you could take bicarbonate salts in the form of BiCarb Formula capsules (available from the Medical Center) or Alka Seltzer Gold (the aspirin free variety) with a large glass of water. Separate doses of Vitamin C and Alka Seltzer Gold by 30 minutes. Alternately you could use Milk of Magnesia or Magnesium sulfate (Epsom salts) to hasten the elimination of the offending food from your body. Contact your physician anytime you have persistent symptoms that concern you.

Recommended Vitamin C dosing:
Children 25-50 pounds
1000-2000 mg daily in divided doses of 250 mg*

Persons 50-100 pounds
2000-4000 mg daily in divided doses of 500 mg*

Persons 100-150 pounds
4000-6000 mg daily in divided doses of 1000 mg*

Persons greater than 150 pounds
4000-16,000 mg daily in divided doses of 2,000-4,000 mg*

Recommended Alka Seltzer Gold Dosing:
Children 25-50 pounds
? effervescent tabs up to twice a day

Persons 50-100 pounds
1 effervescent tab up to twice a day

Persons greater than 100 pounds
2 effervescent tabs up to twice a day

Recommended BiCarb Formula dosing:
Persons 50-100 pounds
1 capsule up to three times daily

Person greater than 100 pounds
2 capsules up to three times daily

* Vitamin C may cause diarrhea in some individuals. Dose it to your individual tolerance. Stop taking Vitamin C if diarrhea develops and reduce your dosage to a tolerated dose upon resuming it. Vitamin C is a water-soluble vitamin and is more effective if take in 3-6 doses a day and not just one dose.

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