THE EASY ELIMINATION DIET

DIETARY INVESTIGATION OF FOOD SENSITIVITY
SUMMARY FOR DIETITIANS

Stage 1. Deciding whether to proceed with a low chemical diet

Who is most likely to benefit from a low chemical diet?

A low chemical diet is more likely to be worth trying if:

* There is a history of allergies in the individual or immediate relatives; for example,
someone in the family has or had eczema, asthma, anaphylaxis, hay fever, hives
etc. Food does not need to be implicated - it may be stress or inhalants.

* Different researchers report more diet responders if eczema, migraine, or irritable
bowel syndrome are present in the immediate family [child, brothers, sisters,
parents, uncles, aunts and grandparents but not cousins].

* The individual can give a specific example of diet causing a definite change in
symptoms or behaviour at some time. They may remember examples of changes in
the past after Easter eggs or parties even though clear changes no longer occur.

* All other possible medical causes for the symptoms have been considered and
some or all of the problems remain.

* Changes in irritability, activity, sleep, concentration or impulsivity cannot be
explained by the normal ups and downs of life.

* The individual is motivated to investigate diet. Note that it is always wise to run a
diet trial under the supervision of an Accredited Practising Dietitian rather than go
for years trying to exclude various foods and additives and not being sure which are
necessary.

How to assess whether dietary investigation is appropriate

Is the referral appropriate? Before the diet trial is commenced, ensure that the
symptoms have been discussed with a doctor. If asthma is present, or if the
individual or any immediate family member has a history of a severe allergic
reaction to any substance, it is even more important that the individual consult a
doctor for advice before commencing the diet trial.

Is the individual ready for a diet trial? Assess the person's motivation and ability to
undergo a dietary trial. For example, if an individual is keen to investigate diet but is
under a great deal of stress, it may be preferable to postpone the diet investigation until
the underlying issues are attended to.
This is a consensus document from Queensland Health Dietitian/ Nutritionists Posted: Feb 2008
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp For review: Feb 2010

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Is the individual's doctor supportive? It may be helpful to contact the individual's
doctor to discuss the dietary investigation, and the possible benefits for the individual. It
is important to seek the person's permission before contacting their doctor.

Do you have the skills to supervise the dietary investigation? Ensure you have
dietetic support if you have not had experience in this area. This Easy Elimination Diet
has been designed to be a good first step for many individuals. Contact an experienced
dietitian if you have any questions.


Stage 2. How to plan the diet trial

2.1 Before the first appointment

When contact is first made ensure that the individual understands that the dietary
investigation may affect what they eat in the future. It is strongly recommended that
there is initial agreement from the patient to attend three consultations over the dietary
investigation period to ensure there is adequate supervision so that the diet will be as
effective and liberal as possible. The recommended consultation plan is in the table
below.

Initial consultation
Second consultation
Third consultation

(After 2 weeks for infants, (Within a few weeks of
after 4 weeks for all
second consultation)
others on elimination diet
trial)

Assess history
Assess individual's
Nutrition assessment
Collect baseline information response
Discuss long term plan
Explain diet therapy
Discuss plans for food
program
challenges



Ensure that the Family Sensitivity History is supplied to the individual to complete
before the first appointment. This saves dietitian time at the first appointment, as it
supplies information on the substances needing most emphasis among all those being
investigated. It also helps the individual see the relevance of family information to them,
so greatly increases motivation.

2.2 At the first appointment

Collect baseline data

Record all symptoms and level of severity, or use a behaviour rating scale (such as the
Rowe Behavioural Rating Inventory) before commencing the diet trial. At the
completion of the diet trial period, this baseline data can be used to assess results of the
trial by having the individual rate symptoms or behaviour again for comparison.
This is a consensus document from Queensland Health Dietitian/ Nutritionists Posted: Feb 2008
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp For review: Feb 2010

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Decide level of strictness for chemical sensitivity

Use the table below to decide which level of diet restriction is most appropriate based on
age of person, motivation, coping skills, and symptoms. Note that you can use different
levels of strictness for different suspect groups. Because the Easy Elimination

Diet is minimally restrictive, it may not show the maximum effect of diet. This level of diet
restriction is not enough for those under seven years of age, those who are already sure
diet has some role in their symptoms, those who know they are quite sensitive or those
with severe symptoms. These individuals will need a more restrictive diet trial.

If the Easy Elimination Diet is chosen, use the following sheets. If a stricter diet is
required, then use the diet resources nominated in the table.


Suspect
Level of strictness
groups
Easy
Moderate
Exclusion, but not
Very strict exclusion

(related to
reduction
absolute


motivation)
(related to


sensitivity)
The Easy
Approximately :
Approximately:
In Anaphylaxis
Elimination Diet


& very sensitive

“The Good Results
The Finer Points Diet people
“The Easy
Diet (in "Are You
(in "Are You Food

Diet”(in "Are You
Food Sensitive")
Sensitive")

Food Sensitive")




The Simplified

Elimination
Diet (Royal Prince
Alfred Hospital
(RPAH))


Additives



Rarely used
Colours
No visible colour
Minimised colour
Excludes colours
{e.g. those
Preservatives
Reduced
[Gallates 310-312,
Excludes
“allergic to the 20th

preservatives
sorbates 200-203
preservatives
Century}


allowed ]

Flavours
Mild flavours
Added flavour
Excludes flavour
emphasised
enhancers
“Additive Free”
“Additive Free”


Natural

Approximately:
RPAH:
In babies & the VERY
chemicals



sensitive:-
Salicylates
Reduced acid
Allow moderate
Allow low salicylate
only one food at a

fruits, juices
salicylates

time
Amines
Reduced
Allow moderate
Allow low amine
introduced

chocolate
amine


Reduced tomato


Glutamates

Allow moderate
Allow low glutamate

glutamate

Natural
Allow vanilla &
Allow vanilla and
flavours
carob
carob

This is a consensus document from Queensland Health Dietitian/ Nutritionists Posted: Feb 2008
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp For review: Feb 2010

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Allergies




Dairy
Reduce only
Reduce or exclude
Exclude as per
Strict exclusion for
Soy
those suspect as
suspect whole
RPAH
anaphylaxis
Peanuts
causing reactions
foods depending on
Wheat
in any family
sensitivity
Tree nuts
member

Eggs

Shellfish

Fish



Suspect
Level of strictness
groups

Sensory Input




Smells
Reduce strong
Where suspect:
Minimise strongly
Minimised In babies

smells
Minimise strong
perfumed products
and the VERY sensitive


smells
Exclude aerosol



deodorants
Taste
Reduce strong

Exclude

tastes
Minimise strong
mouthwashes
Touch
Reduce disliked
tastes

(texture)
textures
Minimise disliked
Light

textures
Noise


Resources &




References
NEMO site
"Diet Detective
"The Simplified
As previous


Method" and "Are
Elimination Diet" and

For information
"Are You Food
You Food
"Friendly Food" by
See also all resources
on theses by
Sensitive?" by
Sensitive?" by
RPAH
on FAIG [Food
Joan Breakey
Joan Breakey
Joan Breakey (DAA

Allergy Intolerance
and Anne
(DAA DINER)
DINER)

Special Interest
Swain (RPAH)
www.ozemail.com.
www.cs.nsw.gov.au/
Group]
refer to web
au/~breakey (Joan
rpa/allergy (RPAH)

sites.
Breakey)



Compiled by Joan Breakey Jan. 2007

Decide what whole foods to reduce or exclude

Continue to exclude any foods the person is already excluding.

If the child is young and the symptoms severe, suspect whole foods should be
completely excluded.

If the person has had competent allergy testing, be guided by the test results to assess
whether further exclusions of whole foods is necessary. Respected tests include RAST
blood tests and Skin Prick tests. Be aware that Skin Prick tests can show false positives.

If whole foods are suspected but there has been no allergy testing, consider limiting
rather than excluding suspect whole foods, especially nutritionally important foods such
as dairy or wheat. Use the sheets “Guidelines for limiting wheat" and "Guidelines for
limiting milk” (Dietary Investigation of Suspected Food Sensitivity, by Joan Breakey).

This is a consensus document from Queensland Health Dietitian/ Nutritionists Posted: Feb 2008
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp For review: Feb 2010

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Review the Family Sensitivity History to assess where emphasis on particular exclusions
should be directed, including whole foods, inhalant allergens and other environmental
chemicals. Summarise these on to the Total Body Load sheet for the patient.

Nutritional Considerations

Most children using this diet need a high energy intake so they need to have all meals
and snacks. Ensure main meal foods are included first. The time between the last food
at night and breakfast should not be more than 12 hours in thin active children.

If whole food exclusions (eg milk) are necessary, ensure that a suitable replacement is
used to provide adequate nutrients (eg protein and calcium).

If there is concern about vitamin or mineral intake, it may be necessary to recommend a
supplement. See RPAH Elimination Diet Shopping List for recommended supplements.

It is important that the individual returns for follow up consultations to ensure adequate
nutrition long term.

Dietary implementation

Select appropriate diet sheets, menu guides, recipes and commercial food list for the
individual.

In infants, the food trial should run for at least two weeks, or until symptoms resolve
completely for three full days if this is sooner. For everyone else, the trial should run for
four weeks or until there are five consecutive days when no further improvement in
symptoms or behaviour is noted.

Ensure the person is advised of withdrawal symptoms. This may occur around the
second day in infants, and the third day in young children. In older children and adults,
withdrawal can appear after a few days and last up to two weeks. Withdrawal symptoms
may include worsening of mood, behaviour and physical symptoms. This can be quite
distressing and phone support may be helpful. Withdrawal symptoms are usually a good
indication that the diet is making a difference.

If the withdrawal physical symptoms are severe (eg migraine), the first week should be
used to gradually decrease suspect foods. This means the withdrawal symptoms may
last longer, but they will be less severe. The trial period is then five weeks.

If the withdrawal symptoms are worsening behaviour, it is important to continue with the
elimination diet at the full level to stop children craving other suspect substances.

It often takes the full four weeks before symptoms decrease. In those under seven years
of age, it is important to review progress after two weeks. If there is no change after two
weeks, fully exclude all whole foods or chemicals that were only limited at the beginning
of the trial.

It is important to follow the diet as strictly as possible during the diet trial to allow for
maximum diet effect.

This is a consensus document from Queensland Health Dietitian/ Nutritionists Posted: Feb 2008
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp For review: Feb 2010

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Mothers of young children may benefit from more phone support. A small mistake re
exclusions or re nutrition matters more in a small child. It is better to have a phone call
and avoid a mistake, than to make a mistake which causes the trial to take longer.


2.3 At the second appointment

Decide on Food Challenges

1. If there has been NO CHANGE in behaviour or symptoms at the end of the food
trial with the Easy Elimination Diet a flood challenge with all the excluded foods for
seven days is recommended. A flood challenge is all the excluded foods at the
maximum level the person usually eats.

If there is no deterioration of behaviour or symptoms after introducing these foods, diet is
unlikely to play a role.

If behaviour or symptoms do deteriorate after introducing these foods, discuss the
following options:

Consider a stricter level of diet trial and discuss with individual to assess motivation,

OR

Revert to the Easy Elimination Diet long term. It is still important to address long term
management of diet and adequate energy and nutrient intake.


2. If there has been IMPROVEMENT in behaviour or symptoms at the end of the
food trial with the Easy Elimination Diet discuss the following options:

Identify particular chemical or whole food sensitivity by undertaking challenges as per the
Diet Detective Method or The Simplified Elimination Diet.

OR

Challenge with favourite foods to see how much of favourite foods can be tolerated.


Stage 3. Long term management

This involves assessment of the various challenges with instruction on gradually testing
small amounts of foods such as dairy or wheat to assess tolerance. See above
publications for details.

Assess the diet for nutritional adequacy.

This is a consensus document from Queensland Health Dietitian/ Nutritionists Posted: Feb 2008
Disclaimer: http://www.health.qld.gov.au/masters/copyright.asp For review: Feb 2010

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Document Outline

• Stage 1. Deciding whether to proceed with a low chemical diet
• Who is most likely to benefit from a low chemical diet?
• How to assess whether dietary investigation is appropriate
• Stage 2. How to plan the diet trial
• 2.1 Before the first appointment
• 2.2 At the first appointment
• 2.3 At the second appointment
• Stage 3. Long term management

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