ADHD, GAPs, FODMAP, Dairy Free: what's the deal with elimination diets?

Cutting out grains, dairy, processed sugar, inflammatory foods, gluten, food chemicals, FODMAPS.....

It feels like there is an elimination diet for just about everything these days. People promoting them often promise a lot! They tout that a specific diet can cure eczema, improve baby sleep, heal the gut, prevent illness, improve behaviour- the list goes on.

The problem is that very few elimination diets are evidence based, or the evidence used to promote them is very poor quality, has been misrepresented or isn't applicable to children or even adults (we often see small scale animal studies being used to scare parents into avoiding foods).  This doesn't mean that there aren't times where a specialised diet isn't useful or needed but for parents it can be really hard to know when this is.

So when might you need to look at a specialised diet or elimination diet?

Firstly, any elimination diet should be done under guidance of a qualified health professional (allergist, gastroenterologist, dietitian for example).  Often they will be done short term, used as a diagnostic tool to determine if there is indeed a benefit for ongoing elimination. If there is, you should then work with a dietitian to ensure you and your little one aren't missing key nutrients. Sometimes, longer term elimination will be needed, for example with severe food allergy, but again this should be decided by a qualified health professional.

When you might need a specialised diet:

• Immediate IgE Food Allergy - diagnosed by an allergist/immunologist usually with skin prick test (alongside history of a reaction when consuming the food). Longer term elimination and reintroduction under medical supervision is needed here.
• Delayed Non-IgE Allergy- diagnosed and managed by allergist/immunologist, paediatrician, GP or dietitian. No skin prick test can be used to test for these allergies. Short term elimination diet of the suspected trigger foods and then reintroduction to confirm this is needed. Children often outgrow these allergies so ongoing re-challenge of trigger foods is appropriate.
• Food Intolerance (to food proteins, food chemicals naturally found in foods I.e amines, FODMAP sensitivities, IBS) are diagnosed and managed by allergist/immunologist, gastroenterologist, dietitian or specialist paediatrician. Some nutritionists or naturopaths may be able to offer support here but not all qualifications are equal. Anyone telling you to avoid a large number of foods for an extended period of time should be approached with caution. Any elimination diet should be used to identify trigger foods and the threshold for a reaction. Avoiding whole food groups for extended periods of time is often unnecessary and can cause harm.
• Diabetes- the type of dietary strategies needed are very individual here! For children with diabetes they will work with a whole team to manage this and a dietitian to create an individual dietary management plan.
• Epilepsy- a ketogenic diet can be used as a medical treatment option for some infants and children.(1) This specialised diet should only be done under strict medical supervision and often requires an inpatient hospital admission to manage before continuing it at home.
• Coeliac Disease- will require a 100% gluten free diet for life. It is diagnosed by a gastroenterologist (usually with a scope under general anaesthetic but can be diagnosed with pathology alone on occasion) and support from a dietitian to meet nutrition needs is recommended. 
• Vegetarian or Vegan Diets- for personal/religious/value based reasons. Again, should have the input of a paediatric dietitian to manage any supplements required and ensure there is no deficiency in iodine, B12, iron, DHA or calcium. 
• Enzyme Deficiency -(Phenylketonuria, Glutaric acidaemia, Maple Syrup Urine Diseasem, Galactosaemia, lactose intolerance in infancy) these are rare and require specialised diets for management.
• Irritable Bowel Disease (IBD) - Rare in infants and children and include Crohn Disease and Ulcerative Colitis. They are sometimes treated with exclusive enteral nutrition (a special drink) an no intake of food for around 8 weeks alongside medical management with medication. Often long term diet is a healthy balanced diet rather than any sort of restriction/elimination.
• Constipation- we can adjust fluid and fibre intake and include specific foods that help too. For some children chronic functional constipation can be a sign of dairy allergy as well. Structure and supervised elimination and reintroduction is needed to diagnose this though.

So why the worry about elimination diets?

We are seeing more and more people trying elimination and speciality diets for their little one's. The main issue with any form of restrictive diet is that they are often done alone, without guidance from someone who is appropriately qualified, experienced and trained to support you and minimise any risk. They are often continued for much longer than is necessary and can have some pretty awful side effects too.

The take home- there are risks with any elimination or restrictive diet.(3)

Long term dietary restriction can:

• Increase risk of nutritional deficiency. In infants and children this is particularly concerning as it can also impact growth and development.
• Increase risk of fussy eating.
• Increase risk of food allergy.
• Less dietary variety and limited food choice can have long term effects on eating behaviour and taste preference.
• Increase risk of feeding difficulties. 
• Often expensive to do and very time consuming.
• Increased isolation as it is harder to go out and see people.
• Increased anxiety about and around food.

If starting an elimination diet means a breastfeeding parents needs to restrict what they eat, there is also a risk for the parent too. There is a risk of undernourishment when whole food groups are avoided leading to challenges maintaining weight, milk supply and a nutritionally adequate diet. We also know undernourishment can make anxiety and depression worse- when postpartum is a period where there is already an increased risk of depression and anxiety. 

Red Flag Diet- These are Elimination Diets That Aren't Supported By Evidence:

• Autism-many types of diet promoted in this space- gluten and casein free is one we see a lot but MINIMAL evidence for it and often means accepted food list shrink and risk of nutritional deficiency increases.
• ADHD - there is no blanket/one size fits all diet for ADHD. Usually a varied healthy diet is what is best (so the same as the general population). Some evidence suggest fish oil supplementation might help with some behaviours but other research say no. Anecdotally we see families cutting out lots of foods (wheat, sugar, food colouring, dairy) with mixed impact. Often any benefit is due to the elimination of a food that was causing gut upset or discomfort (like an intolerance to dairy causing constipation for example) and that leads to improvement rather than anything to do with ADHD. If this is the case only the dairy needs to be limited (and often not totally excluded!) and everything else can be included! Again, this is why getting 1:1 support is important. 
• Eczema-we now know that good skin management should be the first line to treatment for eczema management and not dietary elimination. This can actually increase food allergy risk. (2)
• Gut healing and immune boosting -the GAPs diet is often promoted for this and is not evidence based. We don't need to heal our guts. If they are damaged from something like gastroenteritis, food allergy reaction or coeliac disease- then time and avoiding any foods you're allergic too or gluten if you have coeliac disease is enough. The best thing we can do for immune function is eat a wide variety of foods from different food groups, good hand hygiene, drink plenty of water, get rest. There is some evidence that probiotics might help in certain situations but 1:1 advice on timing and strain is important. 
• Detoxification -our bodies natural detoxify themselves- hello liver and kidneys- so we don't need a elimination diet to do this.
• Improving infant sleep -ignore anyone telling you a diet can help with sleep unless they have a medical condition where something, I.e allergy, is directly causing sleep disturbances. We have heard some professionals promoting starting solids early to help with sleep and to reduce cat napping but there is no evidence to support this. It can actually be dangerous to start solids if they aren't physically ready. There are also no quality studies to support tryptophan foods for sleep or avoiding protein before bed. 
• Paleo Diet and Carnivore Diet- often touted as eating more naturally....the way our ancestors did but they also only lived to 40 years of age. We know a balanced and varied diet is key to good health. A diet high in saturated fat and red meat has been linked with quality evidence to worse health outcomes like increased cancer risk and heart disease. 
• Clean Eating-as long as your food is washed it is clean. Clean eating doesn't improve health but does tend to increase disordered eating and a poor relationship with food. It is also often more expensive and time consuming to eat this way.
• Alkaline Diet- is meant to balance the pH of our bodies but our bodies already do this VERY VERY effectively. If they didn't we wouldn't survive. The foods we eat don't actually change the pH of our blood (thankfully as this would be fatal!). 
• Supplements for children to boost immunity- no evidence they work to help with nutrition or improve health and are expensive. 
• Green/Veggie Powders -minimal to no actual vegetables in these. They are expensive and don't improve health. Often parents include them for "fussy eaters" but it doesn't deal with the root issue and improve food variety and acceptance either. 
• Eliminating food colouring, preservative and additives -we have another whole resource on this but lots of fear mongering in this space. No need to be restricting these in Australia if you don't want to. Limited evidence they impact health/wellbeing/behaviour.

So where to from here?

The take home- is that elimination and specialised diets can have very real benefits to the health and wellbeing of infants, children and parents BUT they should not be undertaken alone. Reach out for a 1:1 consultation with one of our specialised paediatric and allergy dietitians for guidance so any dietary change is done in a way that best supports and nourishes you and your little one. 

References

1. https://www.rch.org.au/neurology/patient_information/ketogenic_diet/
2. Chang A, Robison R, Cai M, Singh AM. Natural History of Food-Triggered Atopic Dermatitis and Development of Immediate Reactions in Children. J Allergy Clin Immunol Pract. 2016 Mar-Apr;4(2):229-36.e1. doi: 10.1016/j.jaip.2015.08.006. Epub 2015 Nov 17. PMID: 26597013; PMCID: PMC4789144 and Mezawa H, et al. (2021) Persistent eczema leads to both impaired growth and food allergy: JECS birth cohort.
3. Yumiko et al. 2020. J Allergy Clin Immunol Pract, 8(5):1721-1724, Martin et al. 2014. Clinical & Experimental Allergy, 45, 255-264, Yamamoto-Hanada K, Suzuki Y, Yang L, Saito-Abe M, Sato M,  Peters, R.L., et al. The prevalence of food allergy and other allergic diseases in early childhood in a population-based study: HealthNuts age 4-year follow-up. The Journal of Allergy and Clinical Immunology, 2017. 140(1): p. 145-153.e8 and Skypala IJ, McKenzie R. Nutritional Issues in Food Allergy. Clin Rev Allergy Immunol. 2019 Oct;57(2):166-178. doi: 10.1007/s12016-018-8688-x. PMID: 29766369.

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