Tools
Elimination Diets
Introduction
An elimination diet is a commonly utilized dietary approach in which a particular food or group of foods is removed from the diet. Elimination diets can be employed to identify and treat food intolerances, food allergies, and other disorders, such as urticarial disease, eosinophilic esophagitis, irritable bowel syndrome, or migraine headaches.[1][2][3][4]
The specific protocol that guides each elimination diet is dictated by the presenting symptoms or established disease process. The elimination process can either be directed by food allergen testing or instituted empirically.[5][6] Highly regimented elimination diets exist, including the gluten-free diet and the low-FODMAP (Fermentable Oligo-, Di-, Monosaccharides, and Polyols) diet. For severe food-related reactions, such as anaphylaxis, other diagnostic avenues, including skin prick tests, serum-specific IgE measurements, or component-resolved diagnostics, can be employed before an elimination diet with oral food challenges is pursued.[7]
Elimination diets have proven efficacy in symptom control and patient satisfaction in various disease processes and are backed by various randomized control trials and observational studies.[8][9][10] This activity reviews commonly utilized elimination diets, the disease processes they may help identify and treat, the limitations of such diets, and the optimal approach to improving patient outcomes through their implementation.
Function
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Function
Elimination diets have proven diagnostic and therapeutic for patients with food allergies or intolerances.[11] Elimination diets also benefit individuals with functional gastrointestinal (GI) disorders, such as irritable bowel syndrome (IBS), which are often triggered by particular foods.[12]
Several approaches to food elimination are utilized in clinical practice; the six-food elimination diet (6-FED) is the most frequently employed approach. The 6-FED comprises 3 distinct steps.
- Step 1: The empiric elimination of the 6 most frequently implicated food allergens: milk, eggs, soy, wheat, nuts, including tree nuts and peanuts, and fish, including shellfish.
- Step 2: Maintain elimination of these food groups for 4 to 6 weeks while monitoring for symptom resolution.
- Step 3: Slowly reintroduce each food group into the diet to identify the culprit that exacerbates symptoms. Once the offending agent is identified, eliminate it from the diet.[6]
One-food, 2-food, and 4-food elimination diets have also been employed similarly to the 6-FED. A 1-food elimination diet removing animal milk has proved comparable to the 6-FED in achieving histological remission in patients with eosinophilic esophagitis.[13] Another approach is eliminating specific food products, such as the low-FODMAP diet for IBS or the gluten-free diet for celiac disease. General elimination diets eliminate and subsequently identify particular foodstuffs associated with symptoms to facilitate arriving at a specific diagnosis. Once a formal diagnosis is made, strictly avoiding the offending food until symptom control is maintained becomes the primary focus.
Issues of Concern
Elimination diets are detail-oriented; multiple barriers to optimal compliance exist. Medical literacy, socioeconomic status, unvarying food choices, and anxiety regarding diets all contribute to incomplete adherence.[14]
Restricted diets can cause nutritional deficiencies. This has been demonstrated in children adhering to elimination diets and in adults with inflammatory bowel disease who choose to exclude major food groups under the preconceived notion that certain foods exacerbate their disease state.[15][16] Patients who follow a strict gluten-free diet are reported to consume less iron, fiber, and carbohydrates than their previous gluten-containing diet.[17] Individuals on a low-FODMAP diet have demonstrated lower calcium intake than controls consuming a standard diet, possibly secondary to the reduced intake of carbohydrates, specifically the disaccharide lactose, a component of calcium-rich dairy products.[18] The low-FODMAP diet has also been shown to alter the gut microbiome, reducing the concentration of bifidobacteria, possibly secondary to the reduced intake of complex carbohydrates and fiber. The long-term impact of this alteration is yet to be determined.[19] Nutritional education is of utmost importance when implementing an elimination diet, as inadequate intake of vitamins and minerals, depending on the specific foods eliminated, can ensue.[20]
Clinical Significance
Food allergies are common and are estimated to affect 3% to 4% of adults and up to 6% of children in the United States. Statistics vary by region and ethnicity; certain populations have a much higher incidence of food allergies.[21][22] Employing an elimination diet with oral food challenges in patients with allergies and intolerances can be a cost-effective and noninvasive method of identifying trigger foods.
Celiac disease is a condition for which the complete elimination of dietary gluten is the mainstay of treatment. The serological prevalence of this disease is estimated at 1.4%, and the biopsy-proven prevalence is 0.7% globally.[23] Remission of this enteropathy is maintained with sustained elimination of gluten-containing food products from the diet. Cross-contamination with gluten-containing food products must also be avoided, as all gluten must be eliminated to allow intestinal healing.[24]
The prevalence of eosinophilic esophagitis is increasing and is estimated at 0.5 to 1 per 1000 people. In North America, eosinophilic esophagitis is present in 2% to 7% of patients who undergo esophagogastroduodenoscopy (EGD) for any indication and in 12% to 23% of patients who undergo EGD to evaluate dysphagia.[25] A stepwise or 6-FED elimination diet is an excellent diagnostic and therapeutic tool for removing inciting allergens, improving symptoms, and facilitating overall disease management.
Patients with IBS frequently benefit from an elimination diet. Symptoms of IBS are common, but the actual disease prevalence varies by country and the formal diagnostic criteria utilized. An 11.2% pooled prevalence was reported across 80 different study cohorts totaling 260,960 patients, though the individual prevalence for each country ranged from 1.1% to 45%.[26] IBS is a commonly encountered clinical disorder, but it is a diagnosis of exclusion; a comprehensive evaluation must be pursued to rule out more severe organic conditions, such as inflammatory bowel disease or celiac disease. Once more severe pathologies have been eliminated through laboratory evaluation or endoscopy, a specific elimination diet, such as the low-FODMAP diet, can be prescribed.[27] Patients following a low-FODMAP diet to manage IBS are advised to eliminate gluten-containing grains, including wheat, barley, and rye; specific fruits, such as cherries, peaches, and apricots; and certain cruciferous vegetables.[28]
Enhancing Healthcare Team Outcomes
Achieving desirable results with an elimination diet is best accomplished with an interprofessional approach. Patients with food allergies or gastrointestinal complaints frequently present to the primary care practitioner, who should obtain a comprehensive medical history and perform a thorough physical examination. The medical history must include a detailed account of the present illness, past medical and surgical history, family history, current medications, and social determinants of health. Guideline-directed medical care should be implemented according to the needs of each patient. Pathologies mimicking the presenting symptoms should be ruled out before assuming a food allergy or intolerance. An elimination diet can be a powerful diagnostic and treatment tool but cannot replace a comprehensive, guideline-directed evaluation. Clinicians must understand the limitations and appropriateness of elimination diets and how to avoid pitfalls that can lead to failure.
Once an elimination diet is prescribed, ensuring the patient understands the specific instructions and goals of the regimen is essential. Registered dieticians can improve patient education by assessing understanding and offering comprehensive dietary instructions. Dieticians can instruct patients on how to read food labels, which specific foods to avoid, and how to avert nutritional deficiencies. The clinical nursing and support staff are also integral to the success of an elimination diet by gathering valuable information about patient compliance, at what elimination or reintroduction stage or step the patient is currently in, and changes in symptomatology. Social workers are essential in cases where barriers to compliance with prescribed elimination diets must be addressed, including socioeconomic status, restricted access to necessary food resources and information, and harmful perceived attitudes toward elimination diets.[14] Elimination diets can be complicated for patients, who may struggle to follow the recommendations. An interprofessional team approach to each patient can optimize treatment, improve outcomes, and provide long-term symptom relief.
References
Wood RA. Diagnostic elimination diets and oral food provocation. Chemical immunology and allergy. 2015:101():87-95. doi: 10.1159/000371680. Epub 2015 May 21 [PubMed PMID: 26022868]
Kliewer KL, Cassin AM, Venter C. Dietary Therapy for Eosinophilic Esophagitis: Elimination and Reintroduction. Clinical reviews in allergy & immunology. 2018 Aug:55(1):70-87. doi: 10.1007/s12016-017-8660-1. Epub [PubMed PMID: 29238902]
Drisko J, Bischoff B, Hall M, McCallum R. Treating irritable bowel syndrome with a food elimination diet followed by food challenge and probiotics. Journal of the American College of Nutrition. 2006 Dec:25(6):514-22 [PubMed PMID: 17229899]
Level 3 (low-level) evidenceHindiyeh NA, Zhang N, Farrar M, Banerjee P, Lombard L, Aurora SK. The Role of Diet and Nutrition in Migraine Triggers and Treatment: A Systematic Literature Review. Headache. 2020 Jul:60(7):1300-1316. doi: 10.1111/head.13836. Epub 2020 May 25 [PubMed PMID: 32449944]
Level 1 (high-level) evidenceRodríguez-Sánchez J, Gómez Torrijos E, López Viedma B, de la Santa Belda E, Martín Dávila F, García Rodríguez C, Feo Brito F, Olmedo Camacho J, Reales Figueroa P, Molina-Infante J. Efficacy of IgE-targeted vs empiric six-food elimination diets for adult eosinophilic oesophagitis. Allergy. 2014 Jul:69(7):936-42. doi: 10.1111/all.12420. Epub 2014 May 9 [PubMed PMID: 24816218]
Zalewski A, Doerfler B, Krause A, Hirano I, Gonsalves N. Long-Term Outcomes of the Six-Food Elimination Diet and Food Reintroduction in a Large Cohort of Adults With Eosinophilic Esophagitis. The American journal of gastroenterology. 2022 Dec 1:117(12):1963-1970. doi: 10.14309/ajg.0000000000001949. Epub 2022 Aug 12 [PubMed PMID: 35971213]
Yue D, Ciccolini A, Avilla E, Waserman S. Food allergy and anaphylaxis. Journal of asthma and allergy. 2018:11():111-120. doi: 10.2147/JAA.S162456. Epub 2018 Jun 20 [PubMed PMID: 29950871]
Atkinson W, Sheldon TA, Shaath N, Whorwell PJ. Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut. 2004 Oct:53(10):1459-64 [PubMed PMID: 15361495]
Level 1 (high-level) evidenceMitchell N, Hewitt CE, Jayakody S, Islam M, Adamson J, Watt I, Torgerson DJ. Randomised controlled trial of food elimination diet based on IgG antibodies for the prevention of migraine like headaches. Nutrition journal. 2011 Aug 11:10():85. doi: 10.1186/1475-2891-10-85. Epub 2011 Aug 11 [PubMed PMID: 21835022]
Level 1 (high-level) evidenceKagalwalla AF, Wechsler JB, Amsden K, Schwartz S, Makhija M, Olive A, Davis CM, Manuel-Rubio M, Marcus S, Shaykin R, Sulkowski M, Johnson K, Ross JN, Riffle ME, Groetch M, Melin-Aldana H, Schady D, Palac H, Kim KA, Wershil BK, Collins MH, Chehade M. Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2017 Nov:15(11):1698-1707.e7. doi: 10.1016/j.cgh.2017.05.048. Epub 2017 Jun 8 [PubMed PMID: 28603055]
Reese I. [Dietary management of food allergies]. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2016 Jul:59(7):849-54. doi: 10.1007/s00103-016-2369-9. Epub [PubMed PMID: 27255299]
El-Salhy M, Gundersen D. Diet in irritable bowel syndrome. Nutrition journal. 2015 Apr 14:14():36. doi: 10.1186/s12937-015-0022-3. Epub 2015 Apr 14 [PubMed PMID: 25880820]
Kliewer KL, Gonsalves N, Dellon ES, Katzka DA, Abonia JP, Aceves SS, Arva NC, Besse JA, Bonis PA, Caldwell JM, Capocelli KE, Chehade M, Cianferoni A, Collins MH, Falk GW, Gupta SK, Hirano I, Krischer JP, Leung J, Martin LJ, Menard-Katcher P, Mukkada VA, Peterson KA, Shoda T, Rudman Spergel AK, Spergel JM, Yang GY, Zhang X, Furuta GT, Rothenberg ME. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial. The lancet. Gastroenterology & hepatology. 2023 May:8(5):408-421. doi: 10.1016/S2468-1253(23)00012-2. Epub 2023 Feb 28 [PubMed PMID: 36863390]
Level 1 (high-level) evidenceWang R, Hirano I, Doerfler B, Zalewski A, Gonsalves N, Taft T. Assessing Adherence and Barriers to Long-Term Elimination Diet Therapy in Adults with Eosinophilic Esophagitis. Digestive diseases and sciences. 2018 Jul:63(7):1756-1762. doi: 10.1007/s10620-018-5045-0. Epub 2018 Apr 2 [PubMed PMID: 29611076]
Lim HS, Kim SK, Hong SJ. Food Elimination Diet and Nutritional Deficiency in Patients with Inflammatory Bowel Disease. Clinical nutrition research. 2018 Jan:7(1):48-55. doi: 10.7762/cnr.2018.7.1.48. Epub 2018 Jan 29 [PubMed PMID: 29423389]
Navarrete-Rodríguez EM, Del Río-Navarro BE, García-Aranda JA, Medeiros M, Enciso Peláez S, García Hernández HR, Pozo Beltrán CF. [Nutritional implications of elimination diets]. Boletin medico del Hospital Infantil de Mexico. 2015 Mar-Apr:72(2):112-117. doi: 10.1016/j.bmhimx.2015.04.002. Epub 2015 Jun 6 [PubMed PMID: 29425990]
Shepherd SJ, Gibson PR. Nutritional inadequacies of the gluten-free diet in both recently-diagnosed and long-term patients with coeliac disease. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association. 2013 Aug:26(4):349-58. doi: 10.1111/jhn.12018. Epub 2012 Nov 30 [PubMed PMID: 23198728]
Staudacher HM. Nutritional, microbiological and psychosocial implications of the low FODMAP diet. Journal of gastroenterology and hepatology. 2017 Mar:32 Suppl 1():16-19. doi: 10.1111/jgh.13688. Epub [PubMed PMID: 28244658]
Staudacher HM, Lomer MC, Anderson JL, Barrett JS, Muir JG, Irving PM, Whelan K. Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome. The Journal of nutrition. 2012 Aug:142(8):1510-8. doi: 10.3945/jn.112.159285. Epub 2012 Jun 27 [PubMed PMID: 22739368]
Level 1 (high-level) evidenceKim J, Kwon J, Noh G, Lee SS. The effects of elimination diet on nutritional status in subjects with atopic dermatitis. Nutrition research and practice. 2013 Dec:7(6):488-94. doi: 10.4162/nrp.2013.7.6.488. Epub 2013 Nov 29 [PubMed PMID: 24353835]
Wang J. Management of the patient with multiple food allergies. Current allergy and asthma reports. 2010 Jul:10(4):271-7. doi: 10.1007/s11882-010-0116-0. Epub [PubMed PMID: 20431971]
Warren CM, Jiang J, Gupta RS. Epidemiology and Burden of Food Allergy. Current allergy and asthma reports. 2020 Feb 14:20(2):6. doi: 10.1007/s11882-020-0898-7. Epub 2020 Feb 14 [PubMed PMID: 32067114]
Singh P, Arora A, Strand TA, Leffler DA, Catassi C, Green PH, Kelly CP, Ahuja V, Makharia GK. Global Prevalence of Celiac Disease: Systematic Review and Meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2018 Jun:16(6):823-836.e2. doi: 10.1016/j.cgh.2017.06.037. Epub 2018 Mar 16 [PubMed PMID: 29551598]
Level 1 (high-level) evidenceAkhondi H, Ross AB. Gluten-Associated Medical Problems. StatPearls. 2023 Jan:(): [PubMed PMID: 30860740]
Dellon ES. Epidemiology of eosinophilic esophagitis. Gastroenterology clinics of North America. 2014 Jun:43(2):201-18. doi: 10.1016/j.gtc.2014.02.002. Epub 2014 Mar 19 [PubMed PMID: 24813510]
Lovell RM, Ford AC. Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2012 Jul:10(7):712-721.e4. doi: 10.1016/j.cgh.2012.02.029. Epub 2012 Mar 15 [PubMed PMID: 22426087]
Level 2 (mid-level) evidenceLacy BE, Pimentel M, Brenner DM, Chey WD, Keefer LA, Long MD, Moshiree B. ACG Clinical Guideline: Management of Irritable Bowel Syndrome. The American journal of gastroenterology. 2021 Jan 1:116(1):17-44. doi: 10.14309/ajg.0000000000001036. Epub [PubMed PMID: 33315591]
Syed K, Iswara K. Low-FODMAP Diet. StatPearls. 2023 Jan:(): [PubMed PMID: 32965895]