How to diagnose and manage multiple food sensitivities ? Dr Janice Joneja

As part of her Q&A series on histamine and salicylate intolerance, Dr Joneja received the following two questions ? both of which called for a very similar response.


Question 1:

I am a 51 year old woman with salicylate intolerance.? I am struggling to find a balance between reducing my symptoms and developing a nutritionally adequate diet.

In the past, the only way I've been able to feel healthy was during the first phase of an elimination diet when I abstained from almost all foods except for turkey, white rice, canned pears and romaine lettuce.? Whenever I tried to introduce a "challenge" food, I developed symptoms.

I'm about to attempt an elimination/reintroduction diet again and would welcome some advice.? What is the best way to go about this to help minimize symptoms?? Specifically, what foods or food groups are best to re-introduce first? And in what quantities?

Question 2:

I seem to have histamine, fodmap, & probably other categories of food intolerances as well.? I have many books on various diets, none of which have helped consistently because they don't take into account the fact that people can be sensitive to multiple categories of foods, as is my issue.? I've struggled with this day & day out for my entire life.? It manifests as digestive & neurological issues, creates social isolation, & generally limits my quality of life greatly.? Do you have any suggestions or resources with info on how to cope with being intolerant of nearly every food?? The DAO products all have additives that I react to, by the way.?

Dr Joneja's answer:

Although these two questions appear to be different, the answers are actually the same, so I will deal with them both under the general topic:? how to diagnose and manage multiple food sensitivities.

There are no diagnostic tests which will, on their own, determine exactly which foods are triggering a person’s symptoms.? Because there are multiple mechanisms responsible for adverse reactions to foods, including allergies and a variety of processes that are loosely termed intolerances, it would be quite unrealistic to expect that a single test would identify them all.? Until we understand a great deal more about the immunological and non-immunological systems that lead to symptoms, we must rely on elimination and challenge to identify exactly which foods are responsible and to avoid them.? So in each of the cases above, an appropriate elimination diet, followed by sequential incremental dose challenge would be the only way to determine the foods responsible for the diverse symptoms catalogued.? When the foods have been accurately identified, a diet must be developed that replaces the culprit foods with ones of equivalent nutritional value.

The process can be tedious and time-consuming, but the results will justify the effort involved because the sensitive person will then have the information required to remain symptom-free for the long term.

I have dealt with the topic of elimination and challenge in great detail in all of my books, so you will be able to follow the directives quite readily.? However, when multiple and complex reactions and diverse foods are involved I always recommend that you enlist the assistance of an appropriately qualified registered dietitian to help you to reduce any risk of nutritional deficiency in each phase of the process.

The elimination diet selected for the initial phase of determining the foods responsible depends on the number of foods and symptoms involved.? The simplest elimination, termed a selective elimination diet, is used when specific symptoms follow fairly regularly when certain foods are eaten, or when the condition itself suggests the type of foods responsible.? This is often evident from the food and symptom record that each person is required to complete.? However, from the data supplied by each of the questioners here, a more extensive elimination would be appropriate.

The next “level” of elimination is the few foods elimination diet in which only about 6 or 8 foods are consumed for 10-14 days, selected on their low allergenicity and evidence that the individual has not reacted adversely when they were eaten in the past. Question 1 indicates that this diet was successful in symptom relief in her case.

In extreme cases, when all foods seem to trigger a reaction, an elemental formula alone is taken until all symptoms have resolved.? The formula supplies all the required macro- and micronutrients in a “predigested” state, typically providing 1,800 - 2,100 calories per day.? Because the molecules are too small to trigger an immunological response or intolerance reaction, an elemental formula will rarely have any adverse effect even when consumed over a prolonged period of time.?

Details about all these elimination diets, including meal plans and recipes for a 14-day few foods elimination diet are available in my book, “Dealing with Food Allergies” (click here to buy the book in the UK; click here to buy it in the US), Part III: Determining the culprit foods and food components: Elimination and challenge procedures (pp 323-395).? The few foods elimination diet, recipes and meal plans can be found in Appendix 1, (pp 397- 439).

When all the symptoms have resolved on the appropriate elimination diet, each food is reintroduced separately in a sequential incremental dose fashion, typically over a 2 or 4-day period.? When a complex food such as milk is challenged, each component is consumed individually: for example, casein, whey, and lactose are all challenged separately, so that a very clear picture of one’s reactivity can be obtained, and nutrients that are tolerated can be included in the diet to increase its nutritional adequacy.? Complete details about the sequential incremental dose challenge, with precise directives and dosages, can be found in my book, “Dealing with Food Allergies” Chapter 28, Reintroduction of foods: Challenge phase, on pages 341-383.? (Click here to buy the book in the UK; click here to buy it in the US) A chart for recording challenge details and any adverse reactions is provided in Appendix 2, Sequential incremental dose challenge, pp 441-462.? If a person has ever experienced a severe or anaphylactic reaction to a food it is very important that such challenges be conducted under supervision in a suitably equipped medical facility to reduce the risk of a life-threatening reaction.?

When you have identified all of your reactive foods, you will need to develop a meal plan that will avoid all of the foods to which you have reacted adversely, and to replace them with nutritionally equivalent nutrients.? Details about how to do this are provided in Chapter 29, The Final Diet pp 385-395.? (Click here to buy the book in the UK; click here to buy it in the US) It is essential to enlist the help of a registered dietitian at this stage, if you have not done so during your testing procedures, because you will need to follow this diet for the long term, so you must be quite sure that it is nutritionally complete and balanced.

?A word of advice:? do not assume anything prior to starting the process of elimination and challenge.? Start with a completely open mind. Many people make assumptions about the foods to which they believe they are reacting, often based on the reading of numerous articles on their signs and symptoms, or questionable methods of testing.? Remember that no one method of testing alone will identify all the foods to which a person reacts.? Whenever a person tells me that they are intolerant of salicylates, for example, I am alerted to the probability that they actually reacting to many different foods (salicylates are present in a wide range of edible plants), and since there is no test that will specifically diagnose salicylate sensitivity, it is important that each food be challenged individually without regard to its possible content of one chemical component or another. Please refer to my article on Salicylate intolerance here.?

Similarly, when histamine intolerance is suggested by a person’s symptoms and the pattern of their reactions while consuming a histamine-rich diet (indicated by their food and symptom record), I advise avoiding a diagnosis of histamine sensitivity until strict adherence to a histamine-restricted diet leads to complete resolution of their symptoms. Click here to read my article on histmaine intolerance.? It is then appropriate for the histamine intolerant individual to follow the histamine-restricted diet for the long term.? Indiscriminate avoidance of whole groups of foods, or numerous different foods without adequate evidence that they are indeed responsible for triggering a person’s symptoms poses significant health risks due to nutritional deficiencies.

July 2015

Comment from Micki Rose - 1st August 2015:
I have read and done Janice's food elimination and challenge process myself and I agree wholeheartedly with her approach. There's just one problem: what happens when you remove the foods, except a few, for the elimination stage but then can't get any of the ones you cut out back in? Read on...