Why and How to Try an Elimination Diet with Sharon Jaeger, RD

Podcast Transcript

Speaker 1: There's so much health advice out there. Lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds; our very own Cleveland Clinic experts. We ask them tough intimate health questions so you get the answers you need. This is the Health Essentials podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Kate Kaput: Hi, and thank you for joining us for this episode of the Health Essentials podcast. I'm Kate Kaput and I'll be your host. Today, we're talking to registered dietitian, Sharon Yeager, about how and why to try an elimination diet. Sometimes the foods we love don't love us back, but if you experience gastrointestinal issues, it can be tough to figure out which foods are causing your symptoms. Today, we'll walk through the steps of starting an elimination diet to help identify the culprit of your concerns. Sharon, thanks so much for joining us today.

Sharon Yeager: Thanks for having me, I'm looking forward to it.

Kate Kaput: Same. I always like to start out by asking people to tell us a little bit about themselves, the work they do here at the Cleveland Clinic and what kind of patients they typically see. So tell us a little bit about you.

Sharon Yeager: I sure will. Well, I am newer to the Clinic just a few months now, very excited about that. I work in functional medicine. Here in functional medicine, we do a very individualized approach to medicine and our goal is to really not just find out that a person is ill, but to find out why they're ill. Really to dig into the root cause of what is causing their problems so that we can find a truly individualized approach to care for them. We always use nutrition first. Nutrition is our first line therapy, so I'm grateful to be one of the dietitians on the team.

Kate Kaput: Perfect. This seems like right up your alley in terms of helping people drill it down and individualize things for themselves. Before we even start about elimination diets, I'd like for you to walk us through some terminology. We hear a lot of terms to refer to our bodies not being able to handle certain foods, so can you give us a little bit of explainer on the differences between terms like intolerance, sensitivity and allergy?

Sharon Yeager: Absolutely, we spend a lot of time explaining this. There are a lot of food foundations to health issues that people have, and many of them can stem from these three things. If you have a food allergy, that is pretty obvious. That is you eat the offending food, an immediate immune response is triggered and you need to do something about it because it's a full-fledged allergy.

An intolerance is a little bit different. It's not really an immune response, it's more a problem with breaking something down. It's about not having an enzyme or reacting to a chemical in a food. For example, histamine in food, some people don't break histamine down. Or the most common you hear of is lactose, that's milk sugar. A lot of people don't have enough of that lactase enzyme and they have symptoms.

Now food sensitivity is a little bit trickier. It is an immune response like an allergy, but it is a much slower response and it often is due to some sort of imbalance in your gastrointestinal tract. You have an imbalance of the good versus bad bacteria, which triggers a food sensitivity and those can take up to three days for a symptom to show up. So it's much harder to link symptoms with a food because of the lag time there.

Kate Kaput: OK, so that's tricky. Can you tell us what kind of symptoms we're talking about for all three of them? I know you said an allergy is a little bit more immediate. What do those symptoms look like?

Sharon Yeager: Usually for an allergy it's something very immediate and that's where you see people carrying EpiPens and they stop breathing, they can't swallow, they go into anaphylaxis. With an intolerance, that's usually a GI symptom or for histamine, a cold type symptom. For sensitivities, it's vast actually. Some people for a sensitivity have very IBS type symptoms where they're going to have nausea or vomiting, diarrhea, or constipation, gas, bloating, a general stomachache. Or you have other symptoms that are harder to identify like migraines or headaches, joint pain, fatigue, brain fog, a lot of those fatigue type symptoms that are harder to pinpoint for certain things.

Kate Kaput: OK, that's really helpful, I think. Sometimes when you think of having trouble with the food, you think of either EpiPens or stomach issues, but it sounds like there can be a gamut in between of things that you might not even recognize as being related to food.

Sharon Yeager: Chronic joint pain is huge. We see a lot of people with autoimmune issues and realize that there are some food sensitivities that go along with that.

Kate Kaput: Oh, interesting. OK, talk to us a little bit about some of those foods. What are the common culprits, whether we're talking about allergies, sensitivities or intolerances?

Sharon Yeager: Yeah, the most common culprits are going to be things like dairy, gluten, which is the protein found in wheat, rye and barley, shellfish or other fish, nuts, peanuts, tree nuts, beef and pork sometimes. Soy is often in there, eggs. Those are the biggest ones. But then there's other things for sensitivities like histamines, nightshades, MSG is a common one that people react to. It's quite a big list, but those are I would say the heaviest hitters.

Kate Kaput: So there's a lot to choose from there. It seems like a better question is, what doesn't cause food issues? Again, before we talk about elimination diets in particular, I want to take a second to discuss the dangers of self-diagnosing. When it comes to food issues, a lot of people seem to diagnose themselves using information they find online or on social media, especially on TikTok. Can you speak to the importance of working with a healthcare professional on these issues to identify intolerances and especially allergies?

Sharon Yeager: Absolutely. The danger here, there's tons of information out there and it's great information if you allow it just to steer you in a direction. But you never want to do any kind of treatment without some type of professional care for several reasons. For example, if you decided you wanted to eliminate everything that I just listed, if you don't have the appropriate person helping you with that, you could end up with a whole host of other medical problems because your diet would be deficient. So you never want to do something like an elimination diet without the help of a dietitian or a physician that's helping you determine perhaps the specific type of elimination you should be on because there are different kinds.

In addition, let's say you had GI symptoms and you cut foods out of your diet and you felt better, but you actually had an underlying disease as well, like celiac or inflammatory bowel disease or something that really needs more vigorous treatment. You could be delaying that treatment or masking that you feel better by changing your diet without actually getting the appropriate testing and the appropriate care, which could really be fatal potentially. So always need to have somebody working on the team with you that is trained to be able to do that with you.

Kate Kaput: OK, I think that sometimes people think that maybe their symptoms aren't bad enough to have to talk to a doctor or, "Oh, this is just how my body is. I just have to live with it." When should you see someone to ask for help if you think that you're having issues? Does it have to reach a critical point? Or is it really just like “hey, you have an upset stomach too often, ask your doctor about it?”

Sharon Yeager: I always err on the side of talk to somebody. If it's something that doesn't seem right, you definitely want to talk. One tummy ache, that's different. But if you're going through an extended period of time with a lot of let's say, bloating, gas, belching, that could be a sign that you have a bacterial overgrowth. If you are chronically having to plan where you're going and how long you're going to be gone, because you're going to need a bathroom. If your pain and debilitation is keeping you from your activities of daily living, you really don't want to wait until that point. You want to figure something out, so you would see a professional pretty early on and that way they can to help you navigate how mild or how essential this is.

For many of us, we have these symptoms for so long, we do think that it's normal and you have people around you saying, "No, that is not normal." If someone is telling you that, you probably do need to see your doctor. And that's why we say get preventative care every year, because these are the questions they're going to ask. You might have not thought of something as being a symptom because that's just the way you are and your doctor would pick up on that and hopefully refer you if necessary.

Kate Kaput: That was actually one of my next questions. Who should you see in this case? Is it best to start with your primary care physician? What kind of other doctors might they refer you out to, or other medical professionals like you, might they refer you out to?

Sharon Yeager: It depends very much on you as the person. I always like to think of your primary care as your partner gatekeeper in your medical care though. They can be the ones that help you navigate the healthcare system. I would always start with them and just be saying, "This is what's going on. What are your thoughts?" They have your history already so they may send you different places than other people might. Then a lot of it unfortunately depends on your insurance as well. For some insurance, you've got to go through your primary first to get a referral.

In other cases, you can self-refer to specialists, but then you might end up doing a lot of hopping if you've chosen the wrong specialist. I always say, start with your primary first, then you can move to specialists. But also know that you're your own best advocate. If you feel like you've been working with people and you're not getting the solutions you need, you may need to switch your primary or switch your specialist or do something that's a little bit more all-encompassing, like a functional medicine where we do a little bit of everything, but we do not replace your primary doctor. We do not replace your specialists, we just work along with all of that.

Kate Kaput: OK, let's say you're trying to figure out what foods trigger symptoms in you. Are there any tests that can help you figure out your food issues without having to go through an elimination diet, blood tests, anything like that?

Sharon Yeager: There are a lot of tests available that can help guide you into the situation. Some of them are great and very helpful, some of them can be helpful, but they are not the whole picture, I guess I would say. They can be parts of what puts your puzzle pieces together, but they aren't definitive. For example, some of the food sensitivity tests or food allergy tests just test for one sort of reaction or one group of foods. Something like MSG or histamine or nightshades might not necessarily be in that test. We always like to say you can use that as part of the picture, but truly even now, the gold standard for figuring out sensitivities is the elimination diet, because everybody is different and every test is just one snapshot in time. We try to use all of that if we need to, to determine what the issue is for the person.

Kate Kaput: OK, let's move into talking about elimination diets. Can you to start just explain to us what an elimination diet is and how it can help you identify those triggers?

Sharon Yeager: OK, the elimination diet really drives down food sensitivities and intolerances. What it does is it removes the most common trigger foods that we see in people. That big list I gave you, there are nine big ones that the Center for Functional Medicine uses, but there are other more tailored elimination diets as well. We can tailor it based on the individual if we need to. But in general, the idea is that you remove a certain set of foods for a period of time, say four to eight weeks. If you have been sensitive to that food, what will happen is with removal of all of those, the inflammation in your gut and the inflammation in your immune system will calm down in hopes that it will repair any inflammatory response that those trigger foods have caused.

Then after that certain period of time, we very slowly and methodically add each food back in one at a time for that three days to check to see if you get any symptoms from that food. That's how we can identify which have been your trigger foods, or if that healing process has worked. Sometimes you can get every single food back in and be fine. Sometimes there's a couple foods you've got to pull out for a couple more months and then try again. Again, very individualized, but it's the best way to figure out those key sensitivities if you need to.

Kate Kaput: OK, and just to clarify, you eliminate a few things at once and then add them back in?

Sharon Yeager: Yes.

Kate Kaput: One at a time?

Sharon Yeager: Yes.

Kate Kaput: What goes into deciding what you're going to cut or what you're going to cut first? I assume that there's some input from a medical professional there. How do they decide?

Sharon Yeager: A lot of it is based on symptoms and history and any diagnoses that you might have. For example, just to use different patient approaches, if you have celiac disease and you come in, we already know you cannot have any gluten. But if there are other issues going on, certain different other symptoms, there might be a few key foods that your practitioner wants to remove. Here in functional medicine, in your first visit you see your provider for an hour. It's an hour long first visit and you have filled out an extensive history on yourself, basically from birth until the day you walk into this office. That is how the provider determines your initial diet. One of those initial things we work on with people could potentially be an elimination diet. A lot of thought goes into it.

If you have another patient that has perhaps multiple autoimmune problems, lots of joint pain, maybe rheumatoid arthritis, something like that, then there's a class of foods called nightshades that we might add into elimination. That's something like tomatoes, potatoes, eggplant and peppers that for some people with those inflammatory autoimmune, they sometimes do better off of those. We can pick and choose that way.

Kate Kaput: So it's really not one size fits all, which I would imagine is another reason to work with a medical professional, right? If you're doing it on your own, you're just cutting things willy nilly and if you're working with a medical professional, they say, "No, let's cut this first."

Sharon Yeager: Right, and one of the key things with that is if you're not doing it on your own and you don't do your reintroductions slow enough, you are not going to be able to really figure out what those trigger foods are. Trust me, elimination is not easy, so you do not want to have to repeat this or you don't want to do it and not find out what your results are for sure.

Kate Kaput: Right, you really want to get it right the first time.

Sharon Yeager: Yes, absolutely.

Kate Kaput: That's a good point, that it's not necessarily just one food, you could be having issues with multiple things.

Sharon Yeager: Yes.

Kate Kaput: You could have celiac disease and be lactose intolerant, right? They're not all mutually exclusive.

Sharon Yeager: Yes, and sometimes a lot of those issues tend to trend with each other. It's very often not one, but you see multiple layers of those problems for people because their gut is out of balance and that affects their immune system.

Kate Kaput: Got it. Talk to us a little bit about how you keep track of the foods and symptoms while you're doing an elimination diet. What are you writing down? How are you keeping track of it? What are the best ways to track those foods and symptoms?

Sharon Yeager: OK, it depends on the individual. One thing that we don't want to do is stress anyone out more than they are. So we leave it up to them on how much they want to track. We have several sources that we use, like a seven day lifestyle and nutrition journal, because it's often that it's all kinds of things that trigger people. You may see that eating something on a less stress free, relaxed day, isn't as big of a trigger as when you're stressed and things like that. So we have a journal where you're writing what you're eating.

You can be tracking the colors of the foods you're eating because with elimination, we're not just working on what you're pulling out, but our focus is really on what you're building into your diet. We're trying to repair through nutrition, so we're building in tons of plant food to help repair and create diversity in your gut. So keeping track of the colors that you're eating. Keeping track of how well you're sleeping, how you're managing your stress, those are all good things. Then when we're talking about symptoms, often how are you feeling that day? What symptoms do you have, so that you can over time start to see those patterns on how all of those things come together to make your symptoms happen. That's helpful for us because it helps us gather information to help assist as part of the team.

Kate Kaput: You talked a little bit about how stressful this can be already. You're having food issues, you have to cut a bunch of things out of your diet, which is really hard to begin with. For so many of us, eating isn't just physical, but it's really emotional and psychological. What tips can you provide to people who might be starting an elimination diet and are feeling restricted and just stressed out about it?

Sharon Yeager: I am one of the people that introduces the elimination diet to our new patients, so we talk about this a lot. Then we have multiple people on our team to help. I think the first thing is to realize that there is a purpose for this and that we will hopefully find some answers for you and that it's short term. That seems to motivate people, that it's just this little while. We would never keep anyone on elimination forever because it is difficult. We all go through it, because as you start with functional medicine, we're all recommended to do the elimination diet so we can empathize with our patients. When we're identifying people for elimination, we are very thoughtful in the fact that this can be very difficult. Especially with somebody with say a history of an eating disorder or not the greatest relationship with food. Sometimes then we will modify that diet or go a different route so that we don't have to build more restriction or create a negative association with food for those people.

So we do have options where we don't do an elimination diet. We focus on increasing variety. We focus on working with our health coaches or working on more of a mind body approach rather than doing significant diet changes. I often am telling people that as you're going through this, perfection's not an option. We're humans, we're imperfect, so there will be mistakes and the food system is set up for you to make those mistakes. I say, "Forgive yourself and move on and use it as an information gathering time. So if you've been eliminating and you accidentally get one of those ingredients, then be very thoughtful of staying in tune with your body for the next three days to figure out if your symptoms changed at all, because you were exposed to that food again. Then bring that information to us." It's really about the back and forth, being forgiving with yourself and just doing the absolute best that you can and letting us know if it becomes a problem, because then we will pivot any way we need to make this comfortable for the patient.

Kate Kaput: I really like that. I know I've felt this way, that one of the reasons you get stressed about trying to figure out what your food issues are, is that it just seems so hard emotionally, not just in terms of what you're eating every day and your menu, but the feelings. So it's nice that you're not just thrown out there like, "Oh, you can't eat any of this now. Good luck."

Sharon Yeager: No, absolutely not because we know food is connection. Food is so much more than just energy in, energy out. We know it's how we connect with people. We have advice on how do you go to a party on the elimination diet? How do you prepare, what do you do if you're going out to eat? Because we know that it's not easy to do in a silo, let alone in the world out there being social. We do the best we can to make them comfortable before they leave with all of the information: Ways to get ahold of us and ways that we can modify if necessary for individualized approach.

Kate Kaput: I'm sure there's a lot more that goes in into this, that you can't go into on the podcast, but can you give us some of those tips? What do you tell people about parties and about going to restaurants and being at events, how to navigate being a person with food restrictions in a world with a lot of really delicious food options?

Sharon Yeager: There are a few things. One of the things I remind people of is remembering that every time you're eating, you're sending a set of instructions to the cells in your body, telling them how to work. When you are thinking about food as medicine and food as information in your body, it does change your perspective on is this the message I want to send to my body? Is this food going to love me back? Again, loving the food that loves you back. That temporary bite of that decadent dessert is amazing and I wouldn't deny that from anyone every once in a while. But the minute after it crosses your taste buds, it is not loving you back, developing that perspective.

For the more practical things, be prepared. If you're going to a party and you know not one thing is going to be something you can eat, then make something that you can take to share with everybody that you know you're safe eating. There's always the opportunity to educate the people around you as well, and to make an impact or pass it forward. You can eat before you go, you can research where you're going or be the one that offers the suggestion of the restaurant you're going to. Restaurants cater so much to food allergies and food sensitivities now, that there are many that you can find that have a special kitchen for preparing, or have certain dishes that are prepared differently. You can't go overboard with this, unless it's something serious like celiac. If you're on elimination, you're going out to eat, your best bet is choose a nice piece of fish, some real vegetables and some rice or something where you're not having to worry about millions of little things and if it's not the correct oil that one to time while you're out, it's OK.

Kate Kaput: That's really helpful. Talk a little bit about reading labels. I guess this is for cooking at home. A big element of doing an elimination diet and of living with food sensitivities is becoming better at reading labels. What tips can you share for people who are trying to eliminate certain ingredients to make sure that they're not still accidentally consuming them?

Sharon Yeager: When reading a food label, try to not rely on the front of the label, because that is more like an advertising. Although there are some rules with regards to that, it still can be misleading. So always turn that package around and refer to the nutrition facts and with elimination, especially the allergen statement and the ingredients list, because that's where you're going to get all of that information. For the allergen list, some of those key eliminated items will be listed there, like the egg and the soy and the dairy and the wheat and the nuts. For other less obvious things, I'm not sure if I mentioned corn is one of the eliminated things, you're going to have to look then up into the ingredients list and see if there's any corn in there.

Things like the oils or other things that even if you're not on elimination, the big health things to be looking for, would be things like all the different sources of your added sugars, the artificial sweeteners that might be in there, the overly processed, overly refined vegetable oils that really are pretty inflammatory. Things like corn oil, cotton seed oil, those really super processed oils will be in there. Really focusing on if the ingredients list is this long, that's probably not something you want to eat, but you want to be able to find identifiable ingredients as much as possible.

Kate Kaput: Got it and learning some of those synonyms of the ingredients too. I know that there are many words for different kinds of sugar that are added into things, for example.

Sharon Yeager: Exactly. We're hoping that that will change, but for now the manufacturers can use five different sugars and that way they're spread throughout the ingredients list. Whereas, if you had to lump all the sugar together, you would see that much higher on the list of ingredients. That's one of the labeling workarounds right now.

Kate Kaput: That is pretty tricky. OK, let's say that you've cut something out of your diet and learn that you do actually have an intolerance or a sensitivity. Once you've removed it from your diet, and you mentioned this a little bit, but just restate it or go a little bit deeper for us, how long does it take to see symptom relief? Can it happen right away? Will it take time? What can you expect or look for?

Sharon Yeager: It depends on the person and it depends on whether it's the allergy, the intolerance, or the sensitivity, or a combination of those. For some people, it can be rather immediate, but for most it takes some time. If you've got multiple sensitivities in your gut and your immune system are inflamed, it's going to take some time to remove those, to lower that inflammation, to clear everything through your system before you're going to see any change. It took a long time to get where these people usually are, so it's going to take a while to get back. It ends up being sometimes very subtle. You'll have a patient come back and say, "Oh, my gosh, I forgot that symptom was there and now I can't remember when it was gone." It's a slow and steady process for most people.

Kate Kaput: That's one of those things like we mentioned, when you start to think, "Oh, this is just how I am," and then you're like, "Oh, that's gone. When did that happen?"

Sharon Yeager: Exactly.

Kate Kaput: Once you discover that you have a sensitivity or an intolerance to something, do you need to completely remove it from your diet, or how can you determine if it's something that you need to fully cut out, or if you just should cut back on it?

Sharon Yeager: Your symptoms, basically how you feel. Again, going back to an allergy or a disease like celiac, we know that gluten for somebody with celiac destroys their GI tract, so that is something you are never going to put back in. If it's something more like a sensitivity, you do the best if you completely eliminate it, but you may find that you can start to work that food back in over time because sensitivities can change every couple of months, depending on your gut health. It's always nice to re-challenge that food, rather than just think that you have a sensitivity and knock it out because then your diet gets so restricted, that that could actually create more sensitivities. So variety is going to be key there.

Kate Kaput: I have friends who are lactose intolerant for example, and they know it and so they avoid dairy products. But every once in a while in the summer they'll be like, "OK, this ice cream cone feels worth it and I just know I'm going to have to deal with it." In that case, it's not something that is causing you lasting harm, right? You just know that you're going to have to deal with some side effects.

Sharon Yeager: You're going to pay the price for a while. But for a lot of sensitivities, it's more symptomatology. It's not that you're damaging anything inside you like somebody with a gluten problem and celiac.

Kate Kaput: Got it. At least you can make an informed decision making process about the foods that you decide to risk it on.

Sharon Yeager: Yes. It becomes a “is it worth it” situation for sure. We learn the hard way many times usually.

Kate Kaput: Yeah, how hot is this day? How good is this ice cream?

Sharon Yeager: Right.

Kate Kaput: That makes sense. So, OK, you mentioned this a little bit, but say it turns out that you're sensitive to a food or an ingredient that is an important part of a healthy diet, something that provides a lot of vitamins and minerals, or you have multiple sensitivities, what are some of your options so that you don't become deficient? How can you make sure that you're still getting what you need?

Sharon Yeager: There are classes of foods. If you have a sensitivity to one kind of food, it may mean that there are other similar foods that you can bring in that would follow the same nutritional profile so that you wouldn't end up deficient. It's always our first choice to work in other foods to be able to cover for that deficiency. If there are multiple foods or it is the entire class of foods that you have an intolerance to, there are certain occasions where your provider would have you taking some sort of supplement or at least checking often to make sure that you're not creating some sort of deficiency.

Kate Kaput: Got it, OK. Is there anything that we haven't discussed today about elimination diets that you think is important for folks to know as they're thinking about their own food issues and what might be next for them?

Sharon Yeager: Just, I guess it would be to know that if you have symptoms of anything... Not anything, but symptoms that you know are questionable, that you've gotten a diagnosis that you're being treated for something and it's working, but maybe you're just still not feeling all the way there, or you can't find an explanation for what's going on with you, something like an elimination diet might actually be very helpful for you to just pair along with your medical care, but get you over that last hump to really start to make you feel well. But again, it's not something you want to do on your own. We would want to make sure that you're getting everything you need so you're not creating a problem by trying to fix a problem as well.

Kate Kaput: Perfect. Sharon, thank you so much for joining us today to talk about this with us.

Sharon Yeager: You're welcome. Thanks for having me.

Kate Kaput: To learn more about the Center for Functional Medicine or to schedule an appointment with a health care team member, please visit www.clevelandclinic.org/functionalmedicine. Thanks so much for being here with us today.

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