Managing diet for suspected food

sensitivity IAAND Nov 2018

Joan BreakeySpecialist Food Sensitivity Dietitian

M App Sc B Sc DNFS Cert Diet TTTC

Diet Investigation of food sensitivity is part of what dietitians can and should do

• Food sensitivity can be complex, but you can learn it in stages

• The conditions often seen are allergic symptoms: asthma, eczema;

• and others: such as irritable bowel syndrome, reflux, migraine, attention deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD)

• My aim is to provide what to do when a patient asks if they may be food sensitive by using my Diet Detective Approach in my DietitiansManual, and also, in Australia, the RPAH handbook

Be confident about practice in 2018

• Much more is known now than in 1970s when Dr Feingold had controversial publicity on ADHD

• Practice and research in Food Chemical Sensitivity in Australia has continued over the last 40 years

• For theory read my thesis, 100 Articles on www.FoodIntolerancepro.com and my books:-

• Diet Manual, Are You Food Sensitive? Fussy Baby, and Tolerating Troublesome Foods, and/or

• The RPAH Elimination Diet Handbook and

• Another APD Mel Reid’s The “simple” elimination diet

How do we name the diet?

• The Low Chemical Diet – my preference, it lowers most additives, salicylates, amines, monosodium glutamate, strong smells and perfumes

• The low salicylate diet – early name in Oz

• The (Royal Prince Alfred Hospital) RPAH Elimination Diet

• Note that the low chemical diet can also exclude or limit dairy or wheat, or any allergen

Some important ideas

• You still use all your diet therapy skills – patient motivation, understanding personal pressures, critical thinking skills. You are just applying them to a new area.

• The presenting symptom does not matter - food sensitivity is in the patient, not in the diagnosis;so the diet investigation, for any symptom the patient presents with, is similar

• The diet is not right on the first day

Before the first appointment

• Keep your focus the on the key question – is food sensitivity present? Has medical care been appropriate? If not delay diet therapy.

• Also delay if alternative therapies are used

• Discuss the diet investigation process – “diet therapy is to find the diet therapy” - using four weeks for the trial elimination diet, one week to challenge, and around 3 to 6 months to refine

• A useful questionnaire is the Family Sensitivity History

The Family Sensitivity History• Symptoms may be ADD, ADHD, behavioural, mood, sleep, physical symptoms e.g. eczema, hives, rashes, anaphylaxis, dermatitis, headaches, migraine, hay fever, sinus, ear aches, asthma,

tummy aches, gut pain, wind, diarrhoea, constipation, reflux, irritable bowel syndrome, mouth ulcers, limb pains, depression. Include any of the above symptoms in any family members.•

• Suspect substances Write in anything that may be suspect. It can include whole foods, additives, inhalants, contacts, smells, medicines, infections, stress etc.• Don’t forget to include symptoms that occurred in infancy too. Note fussiness of any kind as well. Note any sensitivity to smells and stale or strong foods.• Also note if any family member is sensitive to aspirin or NSAIDs• It does not matter if you do not have much before the first appointment, just what you can get easily.•

• Family member Symptoms Suspect substances•

• First family member• [Member investigating diet]•

• Brothers

• Sisters• _ _ _ _ _ _ _ _ _ _ _ _ _ _• Mother

• Aunts

• Uncles•

• Maternal grand-• mother•

• Maternal grand-• Father• _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Father•

• Aunts•

• Uncles•

• Paternal grand-• Mother•

• Paternal grand-• mother

Family Sensitivity History [FSH]is a tool in diet investigation

your patient can fill it out

• It saves time as gives clues for direction

• It shows suspect foods [ chemicals, allergens ]

• It shows variety of symptoms in family

• It gives family info not know otherwise

• It is a motivator as sensitivity owned in family

• It provides focus for your presenting member

• It provides symptoms that can be monitored

At or before the first appointment

• Commitment for 3-month or more program

• You provide a Baseline Diet reducing their known suspects and “the layer underneath”: suspects known from clinical research into all symptoms

• You explain challenges to find main culprit reactions – acknowledging food sensitivity

• You plan to eventually clarify your patient’s own best diet – via many food trials, emphasizing individuality in what is managed

• Appointments continue as long as your patient finds them helpful

Record severity of main symptomsSymptom 1 on a scale of 1 -- - - - - - - - - - - - -10Symptom 2 1 - - - - - - - - - - - - - 10Use RBRI Questionnaire if ADHD, ASD problems

(see Are You Food Sensitive? )

Keep reviewing level of strictness - Depends on

Severity of main symptom

Patient life situation – stressors, barriers.

Patient preference

Patient motivation

Patient skills – still provide Easy Elimination Diet.

Summarise FSH >>>> Total Body Load page

The Total Body Load.

What should you minimise in your family?

Name _____________________________________ Date ____________

Whole foods - circle those not tolerated, or suspect in your family

Infant formula cows milk, goats formula, soy formula, predigested formula

Cows milk goats milk soy milk legumes

Wheat rye oats wholegrain wheat lactose

Peanuts tree nuts onion

Eggs pork beef lamb chicken garlic

Shellfish - crabs prawns lobster Molluscs - scallops, calamari, oysters

Freshwater fish - salmon, perch. Saltwater fish - tuna, cod, sea herring, trout, mackerel, sardines

Additives - colours flavours preservatives

Salicylate group -

Tomato and sauce oranges strawberries dried fruit

Write in others -

Amines - chocolate just-ripe bananas ripe bananas just ripe broccoli

aged cheese aged meats browned meats yeast extracts

Natural spoilage in food – food which smells “stale” to you

Natural Monosodium Glutamate -

Soy sauce tomato paste cheeses yeast extracts wine

Non-food items - Smells - perfumes perfumed plants petrol/paint chemicals

cigarettespetrol/diesel new carpets plastic smells new cars

Skin contacts- finger paint hair dye coloured playdough skin creams detergents

Inhalants windy days

Pollen dust mite moulds grasses animal dander

Infections Stress Hormones

Insect bites Temperature change Seasons

Strictness level>>>>

Suspect groups

“Easy”

The Easy Elimination Diet

Can show presence or

absence of sensitivity

“Good Results”

The Baseline Diet

Using

Diet Detective Approach

“Careful level”

RPAH

Elimination Diet

Handbook

Very strict exclusion

In Anaphylaxis

& very very sensitive

people

Additives No visible colour

Reduced preservatives

Mild flavour

Minimised

Added flavour emphasised

“Additive Free”

Exclude colours

Preservatives

Flavour enhancers

“Allergic to the 20th Century

People would prefer to live in

a ”bubble”

Natural chemicals

Salicylates

Amines

Glutamates

Natural Flavours

Reduced

Acid fruits, juices

Chocolate

Tomato

Herbs, spices

See Manual and AYFS?

Exc High& V high

All moderate redn

All mod redn

Vanilla & Carob

See RPAH tables:-

[allow only low ]

[allow only low]

[allow only low]

[allow vanilla,carob

In babies & the VERY

sensitive:- only one food at a

time introduced

Allergies

Dairy Soy

Peanuts Wheat

Tree nuts Eggs

Shellfish Fish

Reduce only

those suspect as causing

reactions in any family

member

Reduce or exclude suspect

whole foods depending on

sensitivity

Exclude as per RPAH Strict exclusion for

anaphylaxis

Sensory Input

Smells

Taste

Touch [ texture ]

Light Noise

Reduce

Strong smells

Strong tastes

Disliked textures

Minimise

Strong smells

Strong tastes etc.

where suspect

Strongly perfumed products,

perfumes,

Mouthwashes, aerosol

deodorants

Minimised In babies and the

VERY sensitive

Summary: levels of strictness for chemical and food sensitivity

Reduce or exclude whole foods?

• Exclude food

• If patient is already excluding

• If advised by doctor

• If Skin Prick Tests indicate strong reaction

• Reduce food

• If key food e.g dairy or wheat looks suspect see “Diet detective tricks for limiting - - ” in AYFS?

• Or if SPT results do not indicate severe allergy

• Or if using the Easy Elimination Diet

Your patient decides much -

• They decide what they want to do! They have a big role in what is decided.

• Note what they have already found out

• Their intuition is often right; test it

• Remind them to use you to consider decisions

• Not everyone is food sensitive but the patient you are seeing should be taken seriously

Your patient knows about symptoms

• You may not know much about ADHD, ASD, reflux, migraine or IBS to begin with

• But your patient knows much!

• In addition they know about their particular type of their main symptom, and there are variations in each of them

• You are investigating diet for change in their particular cluster of symptoms

• Listen and you will quickly learn much.

Your contribution as the Dietitian

• You help with “critical thinking”

• You help make decisions – an important role

• Patient anywhere from “over whelmed” - - - to - - - keen to get going

• You emphasize individual variation in symptoms, foods tolerated, and times of reactions

• You sort through diet info they already have

• You are the diet therapist, your role it to help each patient determine if they are food sensitive and what their individual diet should be

Flavour matters!

• Additives – flavour 10 times dose of colour

• Salicylates – herbs, spice, mint, teas, acid fruit

• Amines – chocolate, marinades, aged food, high tyramine foods

• MSG – a flavour enhancer!

• In weight control no limit on flavour, limit energy

• In food intolerance no limit on energy, limit flavour

Smells matter!

• Most F-S patients are “Supersmellers” very smell sensitive [some call it ‘fussy’ ]. Use their skill! Minimise all strong smells.

• Liked smells less a problem, but add to ‘TBL’

• “Noticed stale smells” show amine needs investigation - esp in migraine, IBS and ADHD

• Minimise all smells – perfumes, chemicals, fresh flowers, cigarettes, plastics, petrol, etc

• “Even Easier Elimination Diet” – minimise flavoured foods and smells!

Provide Diet Content

• Use the Easy Elimination Diet, the Baseline Diet - Detective Diet Methodor RPAH Handbook

• Discuss Meal Plans

• Discuss Commercial Food lists

• Discuss withdrawal – symptoms get worse before they get better in the first weeks

• Patients age 0 - 4 ‘clear’ in approx 5 days

• Age 4 – 7 “ in approx 7-14 days

• Age 7 on “ in up to 4, (maybe 6) weeks

Resources for your patient• The less experience you have the more

important these resources are• Look on www.FoodIntolerancePro.com

• [Article] section has over 100 free articles

• Books Are You Food Sensitive? Dietitian’sPractice Manual, Fussy Baby, Tolerating Troublesome Foods. Also on AmazonKindle US$5

• RPAH Elimination Diet Handbook www.cs.new.gov.au/rpa/allergy

• All written by APDs

• Patients are motivated to check on the detail.

What are my, or your, hypothesis?

• That the whole group of food chemicals and allergens being excluded may “aggravate the underlying condition”

• That excluding them will give a baseline from which to show individual variation in tolerance of foods and chemicals, and in dose managed

• That Food Sensitive people vary in the foods and chemicals they are sensitive to.

All therapy is testing a hypothesis

HypothesiseTest

AssessRetest

HypothesiseTest

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HypothesiseTest

AssessRetest

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HypothesiseTest

AssessRetest

Second Appointment

• Record changes in severity of symptoms

• Use questionnaire for ADHD or ASD

• Provide information on Challenges:-

• Encourage these to provide long term diet -

• Adapt to patient – see guidelines in resources

• Flood Challenge – return everything high dose

• High dose challenges – groups of chemicals

• Low risk challenges – one from each group

• Single food trials – in the very sensitive

Food sensitive patients – different group

• Supersmellers and supertasters

• ‘Fussy’ = attends to detail, doing investigation

• Can work in steps – gradual dose increase

• Often have cravings – go after a month

• These patients have less lifestyle disorders

• But YOU will be seeing those who overlap!

• FS can occur with overweight, diabetes, etc

• Learn to get a feel for this group

• Separate anorexia nervosa where wt is issue

Follow up during food challenges

• Have patients ring, fax, or email outcomes,

• Some patients do keep in touch, some often!

• Others do not – going OK, so just relax diet,

• Discuss distraction by/with other treatments,

• May have other problems to deal with,

• Often think dietitian not happy unless action is neat and clear; say discuss everything

• Reassure that whatever happens gives info

• Adapt to where they are at, but continue

Some cancel appointments

• Some are very happy with progress and want to work on own, you gave them confidence

• Some do not want to challenge – remind them they have begun so it is worth continuing

• Some start several treatments at once!

• Sometimes the doctor adds medication

• Sometimes family/ professionals not supportive

• Sometimes life events change progress

• Allow the option to return

Third Appointment

• Discuss where their diet is now

• Record implicated foods on TBL page

• Reassure about individual differences

• Note: tolerance can change over time / season

• Diet is not one they go on or off

• It may be get stricter or slacker- symptoms vary

• Discuss decisions to be made over time

• Offer further appointments if desired

The TOTAL BODY LOADCircle what is suspect in your family?

• Additive colours

• Additive flavours

• Most preservatives

• Natural chemicals-

• Salicylates

• Amines

• Mono sodium glutamate MSG

• Suspect whole foods

e.g milk, peanuts , others

• Strong smells

• Contact dye on skin

• Inhalant allergens

• Infections

• Stress

• Insect bites

• Temperature change

• Sensory overload

• Biological maturity

• Hormones

Is Food Intolerance for you?

• This diet therapy can be challenging, patients are complex, therapy is not neat and tidy.

• You can learn quickly from patients, from resources, other experienced dietitians.

• This area of dietetics is fascinating, with great patient variation, you are always learning something new, and you can contribute more to patients and the profession into the future!

• I recommend it!

In closing:

• I have no relevant disclosures and no conflicts of interest.

• I am happy to take any questions