HOW NUTRITION CAN HEAL II ELIMINATION · PDF file“HEALTY DIET” • Junk...

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

,

HOW NUTRITION CAN HEAL II ELIMINATION DIETS

Uncovering Hidden Food Allergies and Sensitivities

2

Balanced sympa/ Parasympa tone

Sympathetic overdrive

DIGESTIVE PROCESS

3

Proper Acidity (pH 1-3)



Acidity Age, PPI, antacids sympathetic tone

DIGESTIVE PROCESS

4




Acidity Age, PPI, antacids sympathetic tone

Healthy mucous layer Poor mucous layer

DIGESTIVE PROCESS

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Acidity Age, PPI, antacids sympathetic tone Healthy mucous layer Poor mucous layer

Intact Immune barrier Permeability

DIGESTIVE PROCESS

6




Acidity Age, PPI, antacids sympathetic tone Healthy

mucous layer Poor mucous layer

Low bacterial growth Bacterial growth

Intact gut-immune barrier Permeability

DIGESTIVE PROCESS

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Microbial abundance and diversity

Dysbiosis/ low diversity


DIGESTIVE PROCESS

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Microbial abundance and diversity

Dysbiosis/ low diversity

Regular BM Constipation/ diarrhea


DIGESTIVE PROCESS

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Requirements for Autoimmunity

1.  Genetic predisposition

2.  Trigger

3.  Intestinal permeability = ”leaky gut”

Intestinal Permeability & Autoimmunity

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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

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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: immediate-type 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

JUNK FREE

CLASSIC ELIMINATION

VERY LOW ANTIGENIC

NO JUNK SOME OF THE

USUAL SUSPECTS

CLASSIC

ELIMINATION

VERY LOW

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


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


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

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

•  Multiple options exist for systematically trialing nutrition patterns in order to optimize our Integrative approach to healing chronic pain

THANK YOU

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