Phase 1: Identify the problem
Week 1: Intro to elimination diet/importance of gut health
Week 2: Identify your food culprits
Week 3: Review how you feel - add in non-GI symptoms, like skin health, fogginess, low energy, etc
Phase 2: Heal your gut
Week 4: Gut healing 101 (leaky gut, pre/probiotics, importance of stomach acid)
Week 5: Consuming properly balanced meals/snacks
Week 6: Getting a variety of foods in
Week 7: Eating out while on an elimination diet
Week 8: Navigate parties, holidays, and special events during an elimination phase
Phase 3: Reintroduction and navigating a new world/your forever diet
Week 9: Be your own science experiment: reintroducing foods
Week 10: Identifying nutritional gaps - vitamins, minerals, etc
Week 11: Check-in on symptoms; reinforce connection between removing trigger foods and improved health. Help patient find substitutes for certain foods if they're really going to miss a trigger food
Week 12: New skills - e.g. working out, meal prepping, etc. Help patient realize the things they may have been missing while dealing with symptoms
Preparation Checklist:
Helpful tools:
Food & Symptom journal/app
Can use MySymptoms Food Diary App (https://www.mysymptoms.net/)
Sample documents:
Calendar - can be helpful for the patient to visualize where they are in the process and plan ahead for reintroduction.
Handout about some common types of elimination diets
To-do’s before each session:
Bring your food journal and note any symptom changes, good or bad.
Introduction (RD script)
Welcome to your 8-12 week elimination and reintroduction diet program. The goals of this program are to guide you successfully through a food elimination and reintroduction trial in order to discover whether there are certain foods that do not work well with your body and are contributing to your symptoms. If you have been dealing with symptoms of GI upset such as bloating, gas, diarrhea, constipation, or nausea, or perhaps other issues such as itching, rashes, or post nasal drip or nasal congestion, brain fog, or poor sleep and you suspect that a particular food (or foods) may be part of the cause, completing an elimination and reintroduction of those foods can help you to identify if in fact that is the case. As a result, you will hopefully reduce or eliminate your symptoms entirely and greatly improve your quality of life.
The great part about working with a dietitian throughout this process is that your RD is an expert in this area. Your dietitian can help you work through questions that may arise, look at your concerns in depth to assess if there are other considerations to take into account as well, and help guide you to your next steps. It is also great to have a support system through this process who can keep you accountable and on track, provide ideas
for alternative foods to try, and ensure that you are not missing out on any essential nutrition even while making dietary changes.
Because it can take time for the body to adapt to and reflect changes that we make in our diets, it is important to recognize that this program will last for multiple weeks. This allows enough time to successfully trial a food elimination, see if that makes a difference in how you feel, trial a food reintroduction, and make any adjustments as necessary along the way. So, if you are ready to dig into this program and make the most of your health, let’s get started!
Phase 1: Identify the Problem
Week 1: Intro to Elimination Diet/Importance of Gut Health
One-sentence description: Describe the purpose of an elimination/reintroduction diet, review the reasons why someone may consider it, and assess appropriateness/readiness for the patient.
Sub-topics:
What is an elimination and reintroduction diet protocol? A short-term diet where you remove a food (or foods) that you suspect may be causing symptoms and test a reintroduction to see if symptoms resolve.
What are they used for? To help reduce or eliminate uncomfortable symptoms that might be related to eating a food that does not agree with your body.
What symptoms might you want to resolve through food elimination? For most people, food elimination trials tend to be helpful with GI symptoms including bloating, gas, diarrhea, constipation, or nausea that other interventions or changes have not been helpful in resolving. Additionally, some people may find this program helps reduce other symptoms such as nasal congestion, skin concerns, headaches, and more. Also, since 80-90% of the immune system is in the gut, a patient can find that their immune system function improves with an elimination diet. Some patients may also see improvements in autoimmune diseases (Hashimotos, eczema, psoriasis, etc).
Difference between allergy and sensitivity/intolerance? A food allergy creates an adverse health event as a result of an immune system response to a food. If a true food allergy is present, the symptoms experienced if ingested can range from mild to something as severe as anaphylaxis. If you suspect a true food allergy, it is best to start by working with your physician to discuss, test, and if a food challenge is needed, to do this under supervision in the event of a severe adverse reaction. An intolerance or sensitivity to food will likely not cause as severe reactions, and can be identified and managed through a diet elimination and reintroduction.
If you have a specific diagnosis where dietary elimination protocols might be warranted, consider working with your RD to discuss if there are particular guidelines to follow for your case (i.e. targeted elimination diet protocols like low-FODMAP diet for IBS vs doing a single food elimination.)
Considerations before beginning a food elimination diet: RD to assess with patient and use clinical judgment to determine if appropriate to move forward.
Any history of disordered eating?
Any mental health concerns?
Does the patient have the time/energy to do it?
Is this a good time – is there a holiday, vacation, birthday, etc coming up that might make sticking with it difficult right now?
Be mindful to not eliminate too many foods or food groups at once in order to avoid missing out on essential nutrition. Discuss with the patient their plans for elimination and guide them on appropriateness.
Recognize other factors that can contribute to GI symptoms – dietary adequacy (consistency, fiber, hydration), exercise, stress, medications, etc. Consider these other aspects prior to beginning elimination to help assess whether it is the correct focus area or not at this time.
Metrics: labs, anthropometrics, symptoms, etc. to check in on
Ask the patient about their experienced symptoms and what foods they suspect may be related to symptoms/why they think that.
Assess what, if any, previous interventions or eliminations the patient has already attempted, whether the elimination was done appropriately, and what the results were.
If the patient complains of certain symptoms but does not know what foods are possibly contributing, consider using your clinical knowledge to help guide them on what could be a factor, and/or ask the patient to start keeping a food & symptom journal over the next week or two to see if they can identify potential triggers.
Advised to also review the patient’s NutriQuiz results and utilize that to help guide appropriate clinical interventions: i.e. if pt eating a very low-fiber diet, consider if it is more appropriate to start with lower-level interventions like increasing fiber and overall diet quality and how that may impact their reported symptoms before moving straight to an elimination diet.
Handouts/activities/homework/recipes if relevant
Have the patient keep a food & symptom log, or review theirs while together if they have already done so.
Review/provide handout discussing some common elimination diet protocols, and discuss with patient what is appropriate for their case, if any.
Key messages: summarize
Review the purpose of an elimination diet, whether it is appropriate for this particular patient’s case per your clinical judgment, food/symptom log.\
Discuss plan with patient if proceeding with an elimination of a particular food or foods, and ensure that they are ready to begin this at or after the next session.
Week 2: Identify Your Food Culprits
One-sentence description: Assist the patient through the process of beginning their elimination phase of the diet.
Sub-topics:
Length: It is advised to do a 4 week elimination phase. Discuss with the patient their willingness, time frame they can commit to, and severity of symptoms (may take longer for symptoms to reduce if more severe so a longer elimination could be helpful). Advise patient that a minimum of 3 weeks of avoiding the food(s) of concern completely is important to the validity of the elimination diet results.
Discuss potential outcomes with patient: If no improvement is noticed in the elimination phase of 2-6 weeks, consider assessing other avenues or trying a different food elimination. There may be another food causing the issue, or another medical consideration. If the patient has been diligent about avoidance but experiences no reduction in symptoms, it can be assumed that the original food of concern is not the problem.
Approach: Discuss with the patient based on their food & symptom log if they think there is one food or multiple that might be causing them issues. Then, help them determine if they should eliminate one food/ingredient at a time (and do multiple elimination/reintroduction trials) or may consider multiple foods at a time. If doing multiple foods at once, ensure that they are able to maintain that restriction and that there are sufficient dietary alternatives to avoid nutritional deficiencies.
Tips to review with the patient: Be mindful to read food labels to ensure that ingredients don’t include foods to avoid. Help patient understand where their food of concern is usually found, as well as how to read ingredient lists to avoid it. Highlight with the patient what foods they should focus on so they don’t feel “restricted” with their eating. Encourage whole foods that don’t contain the eliminated food item. Try to discourage the patient from using too many “replacement” food items, as these can be highly processed and can even cause some GI disturbance.
Meal planning: Assist the patient with meal planning using the Foodsmart app. Help them input their food(s) to avoid in the preferences section (allergens/intolerances) so that they can find recipes that are healthy and will meet their needs during this elimination phase.
Symptom monitoring: encourage patient to monitor for any symptom changes as they go through their elimination phase. If symptoms are improving, that is a good sign and it will likely make sense to continue and move to the reintroduction phase. Remind patient that it may take more than a week to start seeing improvements. The improvements may be immediate, but it may take some patients 3-4 weeks to start to see progress. Review finalized plan for elimination phase: remove concerning/offending food(s) from the diet for agreed upon length of time (at least 3-4 full weeks), ensure nutritional adequacy, confirm that patient is comfortable and confident with plan and meal plan options via Foodsmart app.
Metrics: labs, anthropometrics, symptoms, etc. to check in on
Symptom monitoring as described above
Handouts/activities/homework/recipes if relevant
Have patient continue food/symptom journal if still experiencing symptoms and monitor for changes throughout the elimination phase.
What does this visit look like?
Review last week’s content and ask patient if any questions have come up regarding discussion.
Consider reviewing food/symptom log if patient did not have one at last session.
Explain this week’s content, lead discussion on selected topic(s), ask questions about participant’s thoughts, beliefs, feelings about topic
“What questions do you have for me?”
Key messages: Summarize the plan for this patient to begin their food elimination phase of the diet as per agreement and discussion.
Week 3: Review How You Feel: Add-in non GI symptoms like skin health, brain fog, energy levels, sleep improvements, headache relief, improvements in joint swelling/stiffness
One-sentence description: Time to spend with patient discussing their experience, supporting their journey, and troubleshooting issues that may arise. If the patient feels great, encourage them to continue the elimination and move on to the gut-healing phase. If they don’t feel better, discuss the next potential food to eliminate (some ideas: dairy, soy, egg, low FODMAPS)
If a new elimination is warranted, determine if the initial food eliminated should continue to be avoided. If the patient felt a little improvement/relief with the initial elimination, encourage them to continue avoiding the initial item as you layer in the next elimination. The elimination phase can be difficult to stick with for some people, so encourage the patient to check in with you weekly in order to ensure that they are staying on track and avoiding any pitfalls.
These weeks are a wonderful time to also aid in any meal/food substitution ideas if patient is struggling figuring out what to eat. Spend time helping them create a meal plan in the Foodsmart app, setting their preferences to allow for recipes that fit their needs during this time, and continue to provide alternate ideas as needed. Always and encourage what foods to focus on so the patient doesn’t feel overly restricted.
Handouts:
Easy to follow low FODMAP food list if need be:
Handout explaining the 4 Stages of Elimination and Gut Healing
Phase 2: Heal Your Gut
Week 4: Gut Healing 101 (Leaky gut/intestinal permeability, pre/probiotics, importance of stomach acid and other digestive components)
Review the importance of healing leaky gut, establishing a properly balanced flora, and discussing the use of digestive enzymes and motility agents if warranted (for GERD, bloating, etc). It is important to heal leaky gut and establish improved GI function prior to reintroducing any reactive food components, otherwise, symptoms may return/not improve.
Healing the gut lining: Over time, the integrity of the GI tract can become compromised. This can be a result of chronic stress, simmering inflammation, use of antibiotics, standard American diet, etc. The protective mucus lining can be worn down and lead to intestinal permeability/leaky gut. If this condition is present, food particles can cross the intestinal lining and find their way into the bloodstream. If this happens, food intolerance can develop as well as a variety of autoimmune conditions. It is important to keep this lining healthy and one can do so by incorporating mucilagenous herbs like slippery elm, aloe vera, marshmallow root, and/or L-Glutamine. A patient could also utilize grass-fed collagen powder or bone broth for GI healing. This process typically lasts about 30 days to lay down the protective mucus lining.
Pre/Probiotics: Encourage the patient to initiate an appropriate probiotic. The clinical and therapeutic grade varieties typically provide better results than the lesser quality probiotics. Look for a probiotic that is appropriate for the patients condition (ex: if they have SIBO, a spore based probiotic may be tolerated better, or if they are vegan, make sure you find a probiotic that is not cultured on dairy, etc). A patient can also utilize items like raw sauerkraut, kimchi, miso, kombucha, and so on to support probiotic growth.
Stomach Acid and Digestive Enzymes: A majority of our patients may experience maldigestion from lack of stomach acid. So many are on acid-lowering GERD medications and this further compromises digestion. Encourage patients to take their time with meals and chew meals very well to help take the digestive load off of the stomach. Also, remind them not to drink overwhelming amounts of liquid during a meal as this can further dilute stomach acid. Some can benefit from drinking a small amount of organic apple cider vinegar diluted in water 10-15 minutes before a meal to boost digestive juices. Others can benefit from eating some bitter greens (like arugula) before a meal to get bile moving. Others can find amazing relief by using digestive enzymes before a meal (one that encompasses the enzymes for carbs, protein, and fat). By ensuring improved digestion, the occurrence of bloating is lessened, bowel movements improve, and reflux decreases.
Week 5: Consuming Properly Balanced Meals/Snacks
Check in with the patient and ask how the elimination/gut healing protocol is progressing. Offer mental support and encouragement to continue with the program. Typically, patients feel so much better at this point that their health improvements are enough to keep them going!
Address weight changes. Typically, weight loss occurs on an elimination diet so if this is not a goal of your patient, assess their caloric intake and see where you can support them in maintaining or gaining weight. If weight loss is a goal and their weight remains unchanged, look to see where you can support them in weight loss. Ex: are they consuming empty calorie replacement products? How is their stress level? When was the last time they had their hormones/thyroid checked? Are they getting proper sleep? What is their exercise level?
Ask the patient for an example of their daily intake. Sometimes it is beneficial if they keep a food journal and record their intake for a few days. You can review this food journal to make sure the patient is on track with protein, healthy fats, fiber, carbohydrate, etc. Encourage them to continue to use the Foodsmart app for recipes that exclude their eliminated food items. Share with them what they could use in the recipes to replace their eliminated food (ex: gluten free grain like rice in place of orzo, flax-egg or aqua faba egg in place of whole egg, plant milk in place of cow’s milk, etc)
Remind patients that making a meal plan and creating a grocery list will help them to have food on-hand that they can eat. Having a plan in place and being prepared will help them continue to succeed on the elimination diet. Help them put together a meal plan on the app that is an example of a properly-balanced, allergen free eating plan.
Week 6: Getting a Variety of Foods In
Check in with the patient and ask for an update on their healing process: any changes or improvements in GI function, less brain fog, better energy, improvement in skin symptoms, better sleep, etc. Inquire about supplements and if they are sticking with a gut-healing protocol. If they aren’t sticking with their supplements, encourage and suggest the gut healing foods (as listed above: bone broth, fermented foods like sauerkraut, etc). Sometimes patients tend to choose the foods for gut healing since they are often less expensive than the supplements.
Check in again with their intake. Encourage a variety of foods to support a wide variety of nutrient intake. Discuss different in-season vegetables and fruits that they can incorporate. Challenge them to try different type of protein, have a few meat free days, encourage them to consume adequate amounts of healthy fats, etc.
Continue to provide encouragement and sources for recipes. Challenge the patient to try 1-2 new recipes per week to keep variety in their diet.
This could be a good time to address stress in the patient’s daily routine. Often times, chronic stress can continually wear down the GI lining and compromise digestion. Discuss with the patient different interventions they can use to help balance stress (exercise, meditation, prayer, mental health interventions, supplements like L-theanine or Holy Basil, etc).
Week 7: Eating Out While on an Elimination Diet
Check in with the patient and inquire about improvements/struggles. Ask for an updated weight on the patient. Ask for a few examples of daily intake (breakfast, lunch, dinner, snacks, drinks, etc) to ensure they are still consuming a properly balanced diet with variety.
Ask about the patient’s routine and how often they eat out at restaurants or in their work cafeteria. Often times, patients will order food and just assume that the food they ordered is free of gluten/soy/dairy/egg, etc…. It is best practice that they inform the restaurant wait staff of their food sensitivities so the wait staff can help the patient navigate the menu and choose the foods that are safe for them to consume. The patient can also look online at restaurant menu’s (like fast food establishments) and review the “allergen information” to be better informed about the ingredients in the food.
If the patient is a child and consumes school lunch and needs to avoid certain foods, encourage the patient to ask their primary care physician for a letter stating what foods are to be avoided. The patient can then give this letter to the school so they can continue their elimination in a safe way.
Remind them to continue their gut healing supplements.
Week 8: How to Navigate Holidays, Parties, and Special Events While on a Elimination Diet
Check in on weight, supplement tolerance, improvements in symptoms, etc.
This week is to provide support for the patient and explain how to stick with their elimination diet while they are celebrating the holidays, at parties and or attending special events.
If the patient is going to celebrate holidays at their home and they are in control of the menu, help them plan their menu and make the necessary substitutions to make the food allergen free for them. If they are traveling, discuss some dishes they can make and take along (especially dishes that travel well) with them. If they will be traveling and will be away from home for some time, discuss some snacks they can take along with them that don’t require refrigeration (ex: grass fed beef sticks, trail mix, whole pieces of fruit like apple/banana/orange, etc). Or, encourage them to take a cooler along with them while traveling so they can pack a wider variety of foods. For parties and special events, sometimes it works best for the patient to eat something before they go to the party. Or, take a dish along to share that is free of the eliminated foods. Also, the patient can call the venue ahead of time and inquire about the foods that will be served and the ingredients in some of those foods.
These interventions can be overwhelming for patients and seem like a lot of work. Continue to provide encouragement and support.
Phase 3: Reintroduction and Navigating a New World/Your Forever Diet
Week 9: Be Your Own Science Experiment: Reintroducing Foods
Check in on weight, supplement tolerance, improvements in symptoms, etc.
This week the patient can consider re-introducing the eliminated foods. If the patient does not want to proceed with reintroduction and they feel great following their new eating plan, that is fine. Work with the patient at this point on ensuring they are eating a nutrient dense diet and consuming a variety of plants, adequate protein, and healthy fats. Discuss what a long-term supplement plan looks like (continuing probiotic, working on keeping the gut lining in tact every few months, following up with their primary care doctor for nutrient related labs, etc).
If at this point the patient does not feel any better or symptoms haven’t completely resolved, encourage them to follow up for further gut testing (ex: looking into SIBO, enzyme adequacy, hormone and thyroid balance, etc). Sometimes, functional and integrative physicians can address these symptoms in an effective and healing manner.
If the patient is ready to start reintroduction of foods, begin with re-introducing 1 new food at a time. It is important to not speed through the process, especially if there were multiple foods eliminated. This way if the patient has a negative response, you can pinpoint exactly what the problematic food was.
Have the patient try ¼-½ cup of the eliminated food. Consume that amount of the eliminated food for 3 days in a row. Then, stop consumption and monitor for symptoms for 3 more days. This 3 day monitoring period is important as some food intolerances can affect the person 72 hours after they consume the food.
If no symptoms are present, then the patient can bring this food back into their diet if they want to. Encourage them to consume this food in moderation as sensitivities can re-emerge.
If symptoms are present, remove the food again from the diet and if the patient desires, they can try the food again in a month.
Continue working through all the eliminated foods to monitor tolerance and see if they can be worked back into the patient’s diet.
Week 10: Identifying Nutritional Gaps-Vitamins, Minerals, etc.
Check in to see how the reintroduction phase is going. Has the patient been able to pull more foods back into their diet? Have they been struggling with re-emergence of symptoms? Offer support and suggestions to address any complications or concerns they are having. For the patients that are still struggling with symptoms, remember to encourage them to dig a little deeper into their gut health with further GI testing.
Have the patient provide you with a food intake recall or food journal so you can ensure they are on point with their nutrient intake. This can be especially important for those who are cutting out a whole group of foods like dairy or gluten. If whole food groups are removed, help the patient find alternative sources for the vitamins and minerals that food group contained (ex: calcium, B vitamins, fiber, etc.)
If the patient is working through the reintroduction well and feeling great, this is a good time to touch on other areas of their lifestyle and see if an intervention is warranted. For example, are they sleeping well? Are they exercising regularly?
Week 11: Check-in on symptoms; reinforce connection between removing trigger foods and improved health. Help patient find substitutes for certain foods if they're really going to miss a trigger food
Check in on patient: are they sticking with whole foods, finding ways to prepare meals (if they have busy schedules suggest a meal prep day or a batch cooking day to keep them on track). How is their weight? How are their symptoms? Which supplements are they still taking? Can they wean off any digestive supplements and use them on a PRN basis?
It is very easy for the patient, and common, to start migrating back towards old habits when they start feeling better. They may start to dabble in the eliminated foods again and be less diligent with their intake. Remind them the importance of avoiding the trigger foods due to the inflammation these foods can cause. Inflammation is the root cause of many disease processes so keeping inflammation at bay is important for optimal health.
If the patient is consuming trigger foods again, help them find a replacement for these foods that is made with clean ingredients. It is helpful to know where the patient grocery shops and for the RD to be able to suggest brand names of replacement foods so the patient knows what to look for. You can even show the patient an online picture of the brand of food you are suggesting so they can easily find it in a store. Assist them in finding the food in their area and if their local stores don’t carry the food item, look into the online food delivery options (ex: Thrive Market, Misfits Market, etc).
Week 12: New skills - e.g. working out, meal prepping, etc. Help patient realize the things they may have been missing while dealing with symptoms.
Final check in. Review and highlight the progress the patient has made over the 12 weeks. Maybe they have lost weight, improved blood lab values, slept better, have more energy, better focus, clearer skin, etc. Celebrate these victories with the patient and applaud them on their dedication and hard work.
Look again at other areas of health and wellness in their life and ask them what they are able to enjoy now that they struggled with before. Maybe they are able to be out and about without worrying if a bathroom is close by. Or, maybe they have lost weight and decreased inflammatory levels so that their joints don’t hurt any longer. Maybe they are sleeping great and have more energy. Possibly they have less skin irritation and rashes and they don’t have to be uncomfortable or itchy any longer.
Suggest follow up visits to serve as accountability to keep the patient on track and be able to help them if symptoms start to emerge.
If they are ready, provide them with a new health challenge to work on in between your accountability follow up visits. Maybe they can get to the gym a few times per week. Or, maybe they can try to switch to organic produce. If they have a farmers market in their community, encourage them to get out and try the local fare.
At close, thank them for trusting you with their health and for their dedication in improving their health and wellness.