The Elimination Diet Demystified: From Case Studies to Implementation, With Dr. Kalea Wattles

On Tuesday, November 19th, FMCA hosted a webinar on how The Elimination Diet can help individuals overcome persistent health challenges.

In this insightful session, Dr. Kalea Wattles, Founder of Functional Fertility, joined FMCA’s founder Dr. Sandra Scheinbaum to explore the core principles of The Elimination Diet, practical strategies for implementation, and how health coaches can effectively guide clients through this transformative protocol.

In this webinar, Dr. Kalea and Dr. Sandi discussed:

• The foundational principles of The Elimination Diet and why it’s an effective intervention
• Practical tips for overcoming common challenges during the elimination phase
• A powerful case study showing the positive impact The Elimination Diet protocol can have on health.\
• How health coaches can empower clients through this process

This replay is a must-watch for health coaches looking to expand their knowledge and better serve their clients.

If you’d like to learn more about how the Elimination Diet and Health Coaching, read about how health coaches helped improve Elimination Diet compliance: FMCA Health Coaching Study Published in Medicine®

Watch the Replay

The Elimination Diet Demystified: From Case Studies to Implementation, With Kalea Wattles

Transcript

Dr. Sandi: So, without further adieu, I want to turn this over to our very, very special guest. This is Dr. Kalea Wattles. I have worked with her for quite some time through her position in medical education at the Institute for Functional Medicine. She is an amazing teacher, an amazing person, and she is the one to talk about demystifying the elimination diet. So, take it away, Kalea.

Kalea: Thank you so much, Sandi. Hello, everyone. Welcome. Maybe you’ve heard me talk about the elimination diet before, and you know that this is a beloved intervention to me. It’s one of my most treasured interventions in my practice. So, I’m really excited to be with you all. I love the FMCA community. It’s always so engaging and just really a delight to be with you all. So, let’s get into it. Let’s talk about the elimination diet. I’m going to tell you a little bit about what this food plan looks like, who’s a good candidate. We’ll do some troubleshooting, and then I have a really juicy and fun case for you planned at the end. So, stick with me. Let’s talk about the elimination diet.

I want to just start out with a definition. What is the elimination diet or really what does the elimination diet mean to me anyway? And in the very simplest terms, the comprehensive elimination diet is a temporary dietary intervention that’s designed to uncover food triggers through a dedicated elimination phase that’s followed by a systematic food reintroduction. That’s really important. We’re going to talk more about that. And at this point, I just want to highlight, underscore, bold the word temporary, because this food plan really is not intended for long-term use. The ultimate goal is to get as much diversity back as possible. So, we’re using this short-term. It is an intervention for a therapeutic purpose, just like someone might take a medication short-term, for example. And the reason why I’m being so sensitive about this is because you’ll see on social media or different platforms, people will say, if your doctor recommends an elimination diet or anything restrictive, run. And I certainly agree if that’s a long-term recommendation, but this is a temporary, very short-term intervention, and I think it’s perfectly appropriate and beneficial to be used that way. So, just wanted to highlight that, make sure I’m really clear this is what the elimination diet means to me.

I have some goals whenever I use an elimination diet. Maybe these would be your goals, too, if you were undergoing an elimination diet. My first goal is to remove or identify food triggers. And I think so many of us have had someone say to us this thing, or maybe you have been this person. They’ll say, “I know something I’m eating is making me bloated, making me anxious, giving me hives, but I don’t know what it is.” Maybe they’ve done some experimenting. Maybe they’ve taken gluten out for a week or tried not to eat as much cheese, something like that, but their symptoms haven’t really improved. And they know there’s a food trigger intuitively but haven’t been able to figure it out. That’s where the elimination diet comes into play because it’s very systematic and methodical. And I’ll prove that as we move through this talk.

I also want to reduce the burden on the immune system. And I will tell you in a moment why the specific duration of the elimination diet is so powerful for reducing that burden. So, put a little mental pin in that fact for a little bit, and I’ll come back to it in a minute.

I want to reduce chronic inflammation. And this makes sense, right? If we’re continuously eating foods over and over that we’re sensitive to, we can cause damage at the level of the intestinal barrier. And that damage can increase intestinal permeability, leading to what we call leaky gut. We love to talk about leaky gut because it contributes to so many different health conditions across so many body systems. So, if you need a little refresher, we have these cells that line our intestines and they should have a tight junction. They should be close to each other and really act as a filter so that we’re not letting a lot of things through into our systemic circulation. Now if those cells are damaged, that barrier becomes damaged, particles from inside the intestines like undigested food particles and bacteria and different chemicals can traverse that intestinal barrier where they enter systemic circulation. And our body is wise. Our body knows that those things don’t belong in circulation. So, it is going to cause this whole inflammatory cascade where we have all of these inflammatory cytokines that are floating around. Our immune system will be activated. And if we have symptoms related to our immune system, they’re probably going to get a lot worse. So, I want to lower that chronic inflammation, which is really related to the function of our gut barrier.

So, of course, naturally, one of my goals is to support that intestinal barrier function. Here’s a fun fact. Hopefully this comes up on Jeopardy for someone one day. The cells that line the intestine and form that tight barrier, they’re replaced every few days, like every two to four days. So, over the course of an elimination diet that you’ll learn in a moment is three weeks, those cells are broken down and sloughed off and replaced multiple times. And hopefully that allows for healthier, more robust cells to replace them. As we are removing pro-inflammatory foods, we’re adding foods that are nutrient-dense and anti-inflammatory, we’re helping to really strengthen and fortify that barrier function, which is amazing for so many reasons, especially the type of person that benefits from an elimination diet or maybe the type of person that would request an elimination diet.

I am also always thinking about our microbiome, the little constellation of gut bacteria. We’re always thinking about that in functional medicine. And while this isn’t true for every single person who does an elimination diet, for many people, there’s a pretty significant increase in dietary fiber and polyphenol intake. Those things are going to support a healthy microbiome. We’re shifting towards a healthier microbial composition. So, that’s a really exciting, almost side effect of the elimination diet.

We’re lowering our toxic burden because of the way that the elimination diet encourages organic foods, grass-fed meats, and just inherently we’re not eating as many prepared foods, so it’s lower in food coloring and sweeteners and herbicides and other environmental toxicants. So, it is inherently lowering our toxic exposures.

And then finally, I want to highlight… I said a renewed sense of body awareness, but actually this might be a new and maybe the first time sense of body awareness because we’re asking our clients and patients to very intentionally and thoughtfully correlate the foods they’re eating with how they feel in their body. And I think so many of us go through life eating foods but not really connecting and anchoring into how they make us feel. And this is an invitation and an opportunity to really link those two together. And it’s really insightful and really empowering for people.

So, these are my goals. There’s so many different benefits. I could go on and on about all of the things the elimination diet can reveal to us.

Who might benefit? When we’re talking to our clients, how do we know that they would benefit from an elimination diet? I certainly don’t recommend this to every person who walks through my door. I’m looking at their history, their physical exam, maybe some lab values to help me understand if they would benefit from this intervention. Of course, I’m thinking about this for anyone with digestive issues, especially if they can’t figure out the trigger. And they’re like, “I know something I’m eating is irritating me, but I can’t figure it out.” So, constipation, diarrhea, bloating, heartburn, all of that is fair game. And I’ve seen all of those conditions improve with an elimination diet.

Here’s another layer to this. If you have someone who’s had a stool analysis done already, we can look and see if they have elevated secretory IgA. That’s something I’m looking for or eosinophil protein x. These are going to tell us that they have likely some inflammation at the level of that gut barrier. So, an elimination diet might be really helpful for them.

Rashes or eczema or hives, especially after eating, we know that there is such a connection between intestinal permeability, dysbiosis, our skin, like the gut skin axis. So, we really want to think about that for anyone who has chronic skin symptoms.

Sinus issues, joint pain. We talked about how, for example, intestinal permeability can lead to chronic, low-grade systemic inflammation, and that can impact things like chronic pain. So, if someone has chronic joint pain, chronic muscle pain, we might want to think about how we can lower that inflammatory burden with an elimination diet.

Autoimmune conditions. Isn’t this interesting? Remember how I said, if you have increased intestinal permeability, that is constantly going to be activating your immune system. So, we have almost this hypervigilance in our immune system. So, in my practice, I see a lot of Hashimoto’s or autoimmune thyroid disease, and sometimes an elimination diet can be really helpful in the setting of autoimmunity.

And elevated inflammatory markers on blood work. I’m usually looking for a high-sensitivity C-reactive protein, an HSCRP. And if that’s elevated, I’m going to go diving into all of the reasons why we have this chronic systemic inflammation. I’m going to start in the gut, and usually an elimination diet is going to come into play. So, look for these personas in your clients, and that’s going to give you a little nudge to talk about the elimination diet.

On the flip side, of course, I always want to address who should not use an elimination diet. And this is… We could probably debate about this, but I’ll tell you how I approach this in my practice and the type of client who I might try some other things. The elimination diet might not be the best fit. You can see it’s a pretty short list. I use the elimination diet in a wide variety of different patients, but those who are pregnant or breastfeeding, I tend to avoid the elimination. I certainly have had OBs who have used the elimination diet with pregnant or breastfeeding patients. But here’s a couple reasons why I tend to avoid it. Number one, we’re pushing on our pathways of biotransformation and elimination. We’re really pushing on those detox pathways. And I really want to avoid mobilizing environmental toxicants in someone who is pregnant or they’re breastfeeding so that all of those toxicants are concentrating into the breast milk. So, I try to avoid a lot of detox-centered things in this population. The second reason is this plan and elimination diet isn’t a caloric restriction plan. There’s no guidelines around caloric restriction, but sometimes people do reduce calories for a couple different reasons, inadvertently. The first is they don’t have their normal go-to snacks that they rely on. And so sometimes people just eat less because less of the familiar things that they usually go to are available to them. So, sometimes we just see a natural lowering of energy intake. The second part of it is with all the dietary fiber and the protein people are eating, they might just feel full faster. And they’re not used to that feeling of all the dietary fiber that’s very satisfying. So, sometimes we see a low caloric intake because they’re eating so many low-calorie vegetables and then feeling full. I don’t always want to have a caloric deficit in someone who’s pregnant or breastfeeding. So, I just am very aware of those things.

And then secondly, those with a history of disordered eating, I think this intuitively makes sense. Again, the elimination diet isn’t a caloric restriction plan, but it does frankly remove multiple food groups. And then someone who already has a history of disordered eating, that might be very activating and lead them into some old patterns that might not be so healthy for them. So, I screen for that and I don’t use the elimination diet in those with an eating disorder history in my office.

So, here’s our elimination diet roadmap. I’m going to walk you through this. If you decide that you or your client is a good candidate for the elimination diet, we’re here. We are located now in the three-week elimination phase. And I’m going to walk you through this process all the way till we meet our final destination in our maintenance phase.

You can see here the first component of the elimination diet is the elimination phase, which lasts at least 21 days, 3 weeks. That’s very intentional. That’s very purposeful. The elimination phase is three weeks because it typically takes about 21 days for food-related antibodies to decline in the bloodstream after we move potential trigger foods. And that allows our symptoms, those symptoms that are associated with immune reactivity to subside. To say that in a little bit more of a technical way, the elimination phase is three weeks to account for the half life of IgG antibodies, which is approximately 21 days. So, this duration, this very specific duration allows for those antibody levels to significantly decline, right? Maybe by 50%, which can really reduce that immune reactivity and just create a more clear baseline and a reduction of symptoms before we move into food reintroduction. So, this is very important that we’re making it to that three-week mark, because I think a lot of times people will avoid a food for a week and they’ll say, “Oh, I don’t know, it didn’t really do anything. I didn’t really feel any better.” But we probably haven’t reduced those circulating food antibodies enough to really make a difference in their symptoms. So, the three weeks is intentional. And this is a great opportunity. If you have someone who said, “I’ve already done an elimination,” dive into the details, make sure that they did it long enough so that you can be confident that that was an effective strategy.

I just want to pause here really quick and do a coaching callout, a call for coaching, because this is a time when health coaches can be so, so, so impactful. It’s hard to select a three-week time period of your life when you’re going to do this elimination diet. And there’s never a good time. So, I certainly don’t recommend that people start over Thanksgiving or over their traditional winter holidays. That’s going to be really hard. But no matter when you select your three weeks, there’s probably going to be a work event or some event at your child’s school or your friend is going to invite you out for happy hour. And a health coach can really help clients be prepared for those scenarios, already have a plan for how they’ll navigate that. What will you say? Will you bring food? How do you want to be prepared for those situations? And then to help them remain motivated and really by motivation, I mean anchoring into the why, why they wanted to do an elimination diet in the first place. Is it because you have chronic joint pain and you can’t enjoy sports with your kids that you love to do or you have migraines that make it hard for you to do the work that you love? Figuring out why you wanted to do the elimination diet can help you to remain consistent and motivated when the challenges arise because they will. So, I love to have health coaches as part of the collaborative care team to help us all navigate these situations.

Okay, the natural question, I know you’re all wondering, “Okay, what are we going to eat? Three weeks is a long time. What are we going to eat?” And the first thing I want to say is that the elimination diet I am going to describe is a comprehensive elimination diet. So, I use all the tools and the resources that were developed by the Institute for Functional Medicine, and this is a comprehensive elimination diet. So, it’s very thorough. It’s going to remove multiple classes of highly allergenic and inflammatory foods. Now, not everybody’s going to be ready for this. There’s different variations. You know, there’s a five or six food elimination, or you can just do dairy and gluten if you wanted to. Most of my patients, they are ready for 100% effort. They want the top-shelf food plan. They maybe have experimented already and they really want to go all in on this. So, this is the elimination diet that I personally use. Just wanted to honor that there are variations if you’d like. So, of course, I want to emphasize the foods that we can eat because that’s the most important part. We’re focusing on animal proteins, grass-fed lamb and buffalo, poultry, fatty fish, nuts and seeds with the exception of peanuts, although I believe that’s actually a legume. Dark leafy green vegetables. Think of all the dark leafy greens. That’s actually quite a few foods as well as brightly colored fruits and vegetables. And I know that’s just one point here on my list, but brightly colored fruits and vegetables, that’s a bazillion different foods that someone can choose from. So, the variety is actually pretty vast. We’re focusing on extra virgin olive oil and olives, gluten-free grains, amaranth, buckwheat, millet, quinoa, rice, maybe some grains people aren’t familiar with and it’s really fun to experiment. And then some legumes, no soy and no peanuts, but other legumes are on the table. So, there’s quite a lot of foods that one can eat. Obviously, this is very whole foods based, but they can be combined in really beautiful ways. So, lots of things that we can enjoy.

On the avoid list, we have gluten, corn, eggs, dairy, soy, beef, pork, caffeine, alcohol, trans fats, refined sugar and grain-fed animal foods. So, these are the things that we are avoiding for that three-week period. What I will say is just like any food plan, this is highly customizable. And sometimes I will do some negotiating. So, for example, beef is on the avoid list, and that was initially on the avoid list because many people are eating grain-fed beef, which has a higher omega-6 to omega-3 ratio. So, it’s just pro-inflammatory. But if someone comes to me and says, “I am eating grass-fed, grass-finished organic beef,” I will sometimes make negotiations and we can keep that one. I want it to be realistic for people. So, if that’s a deal breaker, then we’ll talk about it.

I’m just looking in the Q&A and someone asked, “What if we are vegetarian?” That is fine. I have had lots of people do an elimination diet when they’re vegetarian. It’s a little bit more challenging just because you have to be prepared. But if you’re vegetarian and you are very comfortable to get your protein sources through lentils and other legumes and nuts and seeds, it’s fine. It takes preparation, but we can certainly do that. Someone else said, “My own experience is that the foods people tend to eat the most are the ones that they’re most reactive to.” This comes up all the time. So, let’s say if you’re doing food sensitivity testing on someone, right? Usually when you get the results back, they’ll be like, “These are all my favorite foods. What is going on with that?” It makes sense if we look at the intestinal barrier because the foods that are in your system, the ones that you’re eating the most because you love them, will have the most potential to cross that intestinal barrier where your immune system is going to react against them. So, that’s why we tend to be sensitive to the foods that we’re eating all the time, probably because we have a compromised intestinal barrier. So, we’re always making these connections. Chicken and turkey, yep, that’s fine. When you do the elimination diet, we’re really focusing on organic meats, quality as much as we can but yes. Protein powders, I see a question about protein powders. Yes, sometimes we will use protein powders, but I prefer that they are single ingredients, so hemp or pea. Collagen peptides, I really like. There’s lots of flexibility. I just don’t love the protein powders that have tons of ingredients because it can be a little bit difficult to track. The simple, the better. Collagen peptides work great for that. Okay, I’ll try to keep checking in on your Q&A as we move through.

Another call for coaching here though. I really like to help clients maintain variety when they’re in the elimination phase, because if you think about it, someone could do their entire three weeks on apple slices and almond butter, and technically that would be compliant. So, we want to make sure we’re maintaining as much variety as we can. And for some, it’s going to mean experimenting with new vegetables, which is cool and exciting, but it’s great to have that touch point to help people prepare foods in a way that is palatable and to help them experiment with things that might be new, find them in the grocery store, and it’s actually really fun. And you’ll see in the case that I present later can be a really nice opportunity.

Okay, so I’m going to show you this next slide. I have cracked the code, I believe, in how to make the elimination diet really tolerable and easy to prepare for. So, this is my tried and true method that I tell every one of my patients about who does the elimination diet. This is the things in a bowl with a sauce method. I think I’m going to write an entire book just about this method because it works so well for people. So, this is how we go about it. I tell my patients, pick a day of the week and we’re going to do some food prep. I want you to do two sheet pans of roasted veggies. So, I personally like to do one cruciferous sheet, so Brussels sprouts, broccoli, cauliflower, cabbage, and then one sheet of a starchy vegetable, sweet potatoes, butternut squash, acorn squash, whatever they like. So, I like to have two different sheet pans and then chop some leafy greens. So, have your kale or your arugula or even your romaine. It’s chopped up. It’s ready in the refrigerator. Then we’re going to prepare a protein, whether that’s you roast a whole chicken, you make some ground beef, you cook your legumes, you have that ready for the week. So, that’s in the refrigerator. You’re going to make a pot of a gluten-free grain, a rice or a quinoa. Even better if you can make that in some bone broth. That’s going to be ready as the base of different bowls throughout the week. And then here’s the most important life-changing magical part of the whole situation. It’s the sauce. Sauce will change the game in an elimination diet. So, I like to have some different options, chimichurri, avocado cilantro sauce. There’s a Thai almond sauce. I give my patients a recipe. It’s like a peanut sauce, but it’s made with almond butter. We could do a dairy-free pesto, a cashew queso. There’s so many different type of sauce recipes we could go for, and it’s going to add so much variety. So, when I recommend the elimination diet in practice and I give people their after-visit summary, it has all of the resources. I give them toolkit handouts from the Institute for Functional Medicine. And then it has little hyperlinks to different sauce recipes so that they can have that. If you have two sauces in the fridge, think of all the different combinations you can make. With your veggies, you got your grain, you got your protein, you have all these sauces. You can make so many different combinations throughout the week. The other part is if you’re cooking and eating with your family, people will say, “This is so isolating. My family’s not doing it with me. I have to eat something different.” Doing this bowl method allows for everybody to customize. So, maybe you do your bowl, your family puts cheese on it, or they put a fried egg on top. They have their non-elimination diet component. Everybody’s enjoying eating something similar. You can do it together and it just really enhances the experience. So, I highly recommend as you’re working with clients or doing the elimination diet yourself, do the things in a bowl with a sauce method. Just trust me.

Okay. Now let’s move on and let’s talk about what happens. You finished your three weeks of elimination diet. Now we’re going to move into the food reintroduction phase. The key here is that this part of the elimination diet is very methodical, and thoughtful, and systematic. There is absolutely a method and that’s what makes it different from maybe some other things people have tried. But my call for coaching here is that this is the part of the plan where the most mistakes happen. And people have already invested this three weeks into their elimination. It’s hard. It takes a lot of preparation and a lot of energy. And so I want to make sure that the reintroduction phase is really well supported. So, coaches are everything at this time because people need a lot of guidance and support. I tell my patients, “During your reintroduction, portal message me as much as you need.” And having a health coach who can walk people through offer support or even just reassurance is everything.

Okay, so let me tell you how this works. Step one, this is the first day of food reintroduction. We’re going to choose the food we miss the most because of course people have been daydreaming and longing for this for three weeks. So, we’re going to choose the food that they miss the most and that is going to be a big morale boost. So, that means if someone wants to bring back coffee, they want to have eggs again for breakfast, they want to eat corn, that’s all fair game. We’re going to choose the food that we miss the most. Step two, on that day, the first day of food reintroduction, that day and that day only for right now, we are going to eat two to three portions of that food in its purest form possible. So, it’s really important we’re not mixing foods because that makes it really, really hard to figure out what’s going on. So, we’re not going to eat a grilled cheese, right? That’s both gluten and dairy. We are going to choose one food in its purest form and then we have to eat two to three portions of that. So, let’s say we choose eggs, we really miss eggs. A typical portion of eggs is two, and we need to eat at least two portions of that food on our challenge day. So, that might mean four hard-boiled eggs on challenge day, right? So, on let’s say Monday, Monday, we’re going to eat four hard-boiled eggs and then we’re going to move on to the next step.

For the next at least 48 hours, we’re not eating eggs anymore. We ate eggs on Monday. Tuesday and Wednesday, we are not eating eggs. We are monitoring symptoms. So, we only eat the food on the challenge day and then for the next at least two days, we are monitoring symptoms. We’re looking for digestive symptoms, gas, bloating, constipation, diarrhea, heartburn. Looking for joint or muscle pain. Did the food trigger a headache or a migraine? Nasal congestion, increased urinary frequency or think about water retention, bladder pain and someone who might have a chronic bladder pain syndrome, rashes, eczema, I will say hives. If any of those emerge, we would note that. Changes to energy level. I’ll also say changes to sleep, insomnia, mood swings, concentration troubles. Also rapid pulse or anxiety. I don’t know. Maybe you’ve heard people say, “I ate eggs and then I felt really anxious even though nothing was going on.” Maybe it’s because their heart rate is increased and so it’s hard to tell when you have the physical symptoms of anxiety. Is it really anxiety or is my heart racing or I feel sweaty? So, those are all things to know. And if you’re, for example, using the IFM resources, there is a document that’s called the Food Reintroduction Symptom Tracker. If you don’t have access to that, you can have people have a diet journal where they track what food they ate, what time, what symptoms emerged over the next 48 hours and then maybe even some contextual factors like, were you stressed at work? Were you traveling? All of these things. So, we are watching for symptoms for those at least 48 hours.

Let me show this to you in flowchart mode. We’re eating two to three servings of that challenge food, right, in a single day. If there’s no symptoms, good news, that food is yours to keep now. You can continue eating this food and move on to reintroduce the next food. So, you ate eggs, you waited 48 hours, there were no symptoms. You get to keep eggs now and continue to have that. And now you can challenge dairy. So, see, it’s building, it’s cumulative, and you’re adding more and more foods back as you move through reintroduction so it becomes more and more tolerable. And that’s why we want to pick our favorite thing first because hopefully, we’ll be able to keep it. On the other side, okay, we did our challenge. We tracked over 48 hours, there were symptoms. Oh, no, such a bummer. We have to discontinue eating that food and wait for those symptoms to resolve. So, let’s say we ate eggs on Monday and then we had bad knee pain. We have to wait for that knee pain to fully resolve before we move on to the next food. So, even if we have that knee pain for a week, we are not moving on to reintroduce our next thing for a week because it’s going to be really confusing if those symptoms are not resolved. So, once those are clear, we move on to the next challenge food. And I’ll tell you what happens with the guilty foods in a minute.

So, here’s a call for coaching because there are some common obstacles that I think having accessibility to a coach can be really helpful if you have uncertainty around symptoms. So, maybe someone ate the eggs and then they’re like, “Oh, I don’t know. I kind of had a headache, but I was also in a stressful meeting and was grinding my teeth. And I’m not really sure.” People have invested a lot of time and energy into this, so I want to be certain. So, how I approach this is we say, “Okay, we’re going to remove that food. We’re going to take a break from it, move through the rest of your reintroduction. And then we’re going to challenge that food again at the very end.” So, we’re going to move through all the other food groups. And then at the end, we’ll rechallenge eggs. If no reaction happens that second time, it’s likely that that’s not a trigger for you. You can keep it. If you do have that reaction again, okay, that’s a positive finding. We know that that’s probably a trigger for you. Next is deciding when to rechallenge. So, I try to control for as many variables as we can. It’s really hard, but if someone wakes up, they already have a headache. They were grinding their teeth through the night. They had a big presentation coming up and they send you a message and say, “I already have a headache. Should I challenge eggs today?” Let’s say no. We’re going to wait for your headache to resolve. Let’s do it tomorrow and just try to control for those variables. Or if someone wakes up and they’re ready to do their reintroduction… I have a women’s health practice, so this happens to me. They got their period that day. We’re probably going to hold off for a couple of days just to make sure that the symptoms are clear. So, if you’re already feeling crampy, you already have a headache, you’re already nauseous, that’s going to be really difficult to decipher. So, that’s, I think, where a coach can really help us feel confident in the timing of our reintroduction.

People always want to know, “If I react to a food, can I never have it again?” It’s so devastating when you react to something that you really love. Not necessarily. There’s a couple different things I’ll do. So, number one is maybe we want to do a targeted elimination within a certain food group. So, maybe you had two cups of cow’s milk, and you reacted to that. Let’s challenge butter or a cultured yogurt. People react to things differently, like soft versus hard cheeses, or egg whites versus egg yolks. We can do a little intra-category challenging, and maybe there are some components of that group that you do tolerate. So, that’s fair. Option two is we remove that trigger food for 3 to 6 months and then we rechallenge. So, during that time, we’re going to work on the intestinal barrier function, reduce inflammation, tone the immune system, do all the things that we love to do in functional medicine, and then maybe we can bring that food back in 3 to 6 months. See how it’s changed. Maybe you can tolerate that food for a little bit. If you want to have some cheese when you’re at a restaurant with your friend, maybe we can tolerate a little bit. So, let’s try it. We’ll do a break, heal the gut, come back to it.

Okay, this leads us to the final stage, which is the maintenance phase. This is very simple. It means the patient is eating as much variety as they can. They have identified their known food triggers. They are avoiding those for maybe 3 to 6 months. Maybe it’s something that can never come back, and that is unfortunate, but we definitely want to avoid lots of food triggers. So, this person is informed. They are confident. They maybe have developed a new taste for certain foods and have more variety and more vegetables and all these fun things in their diet. Now we’re in this maintenance phase where we are eating for our own body. It’s precise and it is empowered.

I’m going to just peek. I’m just going to peek at the Q&As really quick. Oh, someone asked about nightshades. So, yes, I should have said that. If you were to use a tool like the Institute for Functional Medicine’s Elimination Diet, there are modifications for avoiding nightshades or avoiding foods that cause a histamine reaction. So, if they have a lot of joint pain, we might want to avoid nightshades, or if they constantly get hives or itching, we might want to have a lower histamine burden. So, there are certainly modifications that you can make. It does make the plan more restrictive. So, it’s really important that you’re working with a collaborative care team in that setting.

Okay, let me tell you next about a really exciting case. I’m just watching the clock, so it’s going to be a little bit quick but it’s okay. It’s really, really interesting. So, I have a fertility practice. So, a lot of my cases are related to unexplained infertility or some kind of reproductive health condition. So, this is a patient that has PCOS chronic inflammation. This is a 33-year-old female. She was diagnosed with PCOS in 2010. She wasn’t ready to have a family at that point. She was just, kind of, not really worried about it, even though from 2010 to 2016, she only had about four menstrual cycles. So, I mean, months and months and months would pass between having a period. In 2016, she gets married. She decides, “I really want to start a family.” So, she goes to her PCP. She is prescribed metformin because of insulin resistance being a main driver of PCOS, spironolactone for the androgen, the high testosterone, and then provera.

After about 6 months, she gets pregnant. She’s so excited, but she has hypertension during her pregnancy, lots of inflammation, lots of water retention, lots of swelling. And she has to be induced at 37 weeks due to preeclampsia. And it’s really scary. The whole birth, she felt it was very traumatizing. It was very intervention-heavy. She was very worried about her safety, the baby’s safety. Fortunately, her baby is born healthy, but it leaves her feeling sad about her birth experience. From 2020 to 2023, she’s happy she has her baby, but she wants to give her child a sibling. And so she’s trying to get pregnant. She starts working with the local fertility clinic. And unfortunately, over that time, she has four miscarriages and three unsuccessful intrauterine inseminations. And it’s really devastating. Every time she has to use medication to get pregnant, and she just is feeling like her body is not cooperating, and it’s really tough. Fall of 2023, she’s exhausted. She decides to take a break from fertility treatment and her meds and focus on the foundations of health. She starts doing juice fast. She read about that. She starts doing juice fast. She’s taking a prenatal vitamin, NAC 600 milligrams three times per day. She’s doing omega-3 fatty acids. And then she discontinues metformin. She decides she’s going to do berberine 500 milligrams three times a day for her insulin. She does that on her own. So, she gets to me very early in 2024. At that point, her cycle lengths are still 60 to 90 days, so really unreliable, sometimes even a little bit longer. She’s experiencing alternating diarrhea, constipation, heartburn, bloating. She’s unable to lose weight, even though she’s following what she describes as a low-carb diet. She’s buying all these keto breads and really feeling restricted because she’s eating something different from her family every night at dinner. And she’s just frustrated and worn out and over it.

So, we start with some blood work. I have a preconception panel that’s like 30, 32 different biomarkers. If you’re interested what that looks like, you can go to my website, drKalea:wattles.com, and just right there on the homepage, it’ll say preconception lab checklist. You can put in your email if you’re just curious about what I order. Many, many biomarkers in the preconception phase, but I want to highlight some of the most profound findings from her preconception panel. So, we did a fasting insulin. This is fasting. It was 40.6. Now, to give some perspective around this, for fertility, I like to see a fasting insulin below five. I usually say below eight is good for me. Below five is better if we’re thinking about reducing risk for things like preeclampsia.

So, this was stunningly high. We also look at her total testosterone, which was very high. So, in a patient with PCOS, I’ll often see this in the 60 to 80 range, which is certainly high enough to disrupt ovulation. Hers is 126. This makes sense, right, because hyperinsulinemia makes the theca cells in the ovary get bigger. They’re pumping out testosterone. So, that makes sense, but definitely disrupting her ovulation. Her HS CRP, this is an inflammatory marker, was 4.8, which is elevated and matters to me for a lot of different reasons. Number one, levels above 3 are associated with higher risk for cardiovascular disease. So, I want to get a hold of this not only for her fertility but for her longevity so she can enjoy her family. We also know that chronic systemic inflammation can impact the ovaries. So, we have ovarian atrophy, which is a wasting away of the egg cells. It can also impact the endometrium, that inner lining of the uterus, and impact endometrial receptivity. So, even if she was fertilizing an egg, it might not be implanting in her endometrium. And then uric acid, this is famous because it causes gout, right? But some of my mentors like Dr. Michael Stone, who’s delivered with his wife something 6,000 babies, has taught me that uric acid increases our risk for pregnancy-induced hypertension, preeclampsia. I run this on all my preconception patients. And so knowing this patient’s history, I really wanted to run this and you can see it’s elevated.

So, we did a comprehensive elimination diet. She came to me wanting to do this. So, of course, we utilized an elimination diet. She was already walking 15 minutes most days of the week. We increased that to 30 minutes, 5 days per week. I know that maybe seems like a lot, but it wasn’t actually a huge increase in her physical activity. It felt really reasonable to her. I initiated some cyclical progesterone therapy. So, for me, I do 200 to 400 milligrams progesterone two weeks on, two weeks off, two weeks on, two weeks off just to try to mimic that normal cyclicity of someone who’s ovulating and making progesterone. I find that if we do that three cycles or so, it can kind of support the brain-ovary communication, so we did that. And then I enrolled her in an online course I have called Insulin Essentials. And the reason why I’m saying this is because this is a real opportunity where a coach could really help because I’m fortunate that I had these videos recorded already that talked about what insulin resistance is, how it impacts fertility, and then how it impacts inflammation, which was really relevant to this patient. But if you didn’t have those, having someone who could walk patients through that process, who could record videos, who could do group classes around that is an amazing opportunity for education. And then the patient stayed on her supplements. We decided we’re not going to make a lot of changes to her supplements. We’re really going to focus on this elimination diet for three weeks. And then we’ll come back and refine some of the other things that she was doing.

So, she did her elimination diet. Really exciting. She lost 12 pounds over the course of the three weeks, and she hadn’t been able to lose any weight for years. She reported more energy. She had no more bloating or heartburn for the first time in years. She thought she wasn’t a vegetable person. She told herself the story, “I’m not a vegetable person.” And now she was eating and loving vegetables with every lunch and dinner. So, how amazing that she was like, “Wow, I just didn’t know.” And then this whole variety was open to her. And then she reported feeling more at home in her body. And as a practitioner, that is so rewarding to hear that someone feels more safe and at home in their body. So, very exciting. We repeated the labs. Three and a half weeks after she started that elimination diet, look what happened. Her insulin came down from 40.6 to 22.5. It dropped to almost in half in three weeks, which if you think about, she had had this hyperinsulinemia and PCOS for 15 years. And now we dropped her insulin in half in three weeks. Her testosterone was still elevated. It was at 123. So, that didn’t come down very much. We knew we still had a lot of work to do. The insulin is still high. I still had a goal to get that much lower, but that was great progress. Look at her CRP. It was 4.8 before, came down to 2.1, dropped more than half in just three weeks. I find that the higher the CRP I’ve had be over 10 before, it will drop pretty significantly with an elimination diet. And then her uric acid came down into the normal range as well. So, that was just in three weeks. And we knew that we could continue working. We were so excited.

So, what happened next? She moved through her reintroduction phase, was able to add back all the foods except for gluten and corn. Even after moving through reintroduction, though, she maintained a higher protein and vegetable intake. And I think that’s an effect of the elimination diet I always want to highlight is people learn new skills. They find foods that they love, and oftentimes they’ll carry those principles even when they’re done with the elimination diet. And then one month after completing the elimination diet, she got a positive ovulation test, which this was the first time this has happened in years. We were so excited and it was so reassuring that we were on the right track.

So, then a couple weeks after this, after she tells me that she got her positive ovulation predictor test, I opened my portal message and there is a photo of a positive pregnancy test. So, of course I sent the patient to the lab. We measured her HCG. I do it baseline and then again, 48 hours to see if it doubled. It did. It just more than doubled. This was the first time this patient has ever fallen pregnant without ovulation induction medication. So, she was shocked. I was quite frankly shocked. We were so excited with her loss history. We were still really cautious, but she continues to be monitored by her OB. And now she is over halfway through her pregnancy with a healthy baby boy. So, this is just so rewarding. I know this is just a really wild example. It doesn’t always happen like this, but I wanted to show you this because these things that lower inflammation, that tone the immune system can just go so far and help people achieve their health goals. So, really a fun example.

As we close this whirlwind tour through the elimination diet, I want you to think about the elimination diet in a couple of different ways. Think about it as a temporary short-term but really powerful tool to uncover food triggers and to help patients add precision to their own dietary needs. Think about benefits that are beyond just gut health. We’re reducing systemic inflammation. Of course, we’re supporting gut healing, but we’re really enhancing overall well-being across multiple body systems. And then this empowered reintroduction. Like I said, this is very thoughtful and methodical. And so think of this as a way for patients to mindfully connect their food choices with their symptoms, which fosters such a sense of awareness and sustainability.

Thank you so much, everyone, for being with me and tuning in from all over the world. I’ll stop sharing here and welcome Sandi back and we’ll do a little Q&A. And just thank you so much, everyone, for your attention and your thoughtful questions. I love being with you all.

Dr. Sandi: Well, thank you, Dr. Kalea. That was a very, very powerful presentation. I know I learned a lot. I always do. And I want to turn everyone’s attention to the opportunity for Q&A. We will not have time to get through every question, but we will do our best to post answers to many of these. And you also will have the recording of this presentation.

So, let’s just begin here. We have a question that had to do with, “Should we discontinue herbal therapies while we’re on the elimination diet?”

Kalea: Great question. I do. I will mostly have patients discontinue all non-essential supplements and medications. So, certainly if they’re on a prescribed medication to control their blood sugar or their blood pressure, all of those things stay. But we do monitor them because we see people get more insulin-sensitive, as you saw from that case. So, we do monitor their medications if needed. But I’d also discontinue most herbal botanical products and most supplements, to be quite frank, unless it’s something that’s managing a chronic condition. Sometimes with my patients who are doing this preconception, I’ll have them stay on their prenatal vitamin, but I do discontinue most things for that three weeks.

Dr. Sandi: Got it. How about the length of time? The question about being on it for more than four months. That was suggested by a nutritionist.

Kalea: Yeah, that’s pretty long. I don’t tend to go quite that long. Now, there’s always, like I said, a degree of customization and precision. So, let’s say I’m working with someone and they finish their three-week elimination and they say, “I am feeling 75% better. My symptoms are 75% resolved. I can definitely see I’m moving in a trajectory of healing, but I’m not quite feeling 100% better yet.” I might say, “Let’s go three more weeks.” But this is the person that I know has a lot of variety. They are comfortable in the kitchen. They are able to do food prep. They are not feeling deprived. They feel confident and comfortable to do three more weeks. I will. I personally have never gone beyond six weeks. That is my limit. I say, if we’re not there in six weeks, let’s try something else. But you can continue on a little longer if you need to.

Dr. Sandi: What about food sensitivity tests? Do you do them simultaneously or is it either/or? What would you say regarding that?

Kalea: Everybody has their own style. So, I will say this is my approach. Others will not have this approach. I almost never order food sensitivity testing because what happens in my practice, I order the testing and then we have to do the elimination diet anyway. And so I usually start there and say, “Let’s do the elimination diet. See how you feel.” If we do that and we don’t really get the symptom improvement that we thought we would, then I might consider doing the testing, which I think is opposite of what a lot of people do. But that’s my approach because I feel so comfortable with the elimination diet. I know that’s not true in every practice, but I always start there. Really, the elimination diet is the gold standard for identifying food issues. So, that’s my go-to.

Dr. Sandi: Sounds good. What about if we believe they have SIBO?

Kalea: Yeah, do the SIBO testing. Certainly do the SIBO testing because that can help you tailor your elimination diet even more. So, in that situation, someone might benefit from a low FODMAP diet, for example, which is going to look a little bit different than the comprehensive elimination diet. So, I love it. And sometimes I’ll start an elimination diet just to get the ball rolling. We’ll do the SIBO testing because results can take a little while. And then we’ll add precision later if we need to. But yes, that is one that I do order.

Dr. Sandi: Okay. Here’s a question I never had come up before, but isn’t poultry grain-fed?

Kalea: Yes, it certainly can be. We don’t see… from my understanding. I’m not an expert in poultry composition, but we don’t see the same level of omega-6 fatty acids in poultry that we do in beef. So, I think that the poultry issue is just less profound than in some of our red meats.

Dr. Sandi: Okay. Related question. During reintroduction, would you have them reintroduce grain-fed meats or grass-fed?

Kalea: The preference is always going to be grass-fed. If we have access to grass-fed, grass-finished, organic beef, that is preferable. But I also really want to honor that is not accessible to everyone. And so sometimes the beef that they are consuming is grain-fed. It’s a great source of protein. We do what we can. And so if that’s what’s accessible to someone, and that’s what they’ll be able to eat long-term, then that’s what we rechallenge with.

Dr. Sandi: Sounds good. After that, vegetarian, allergic to all starches, they can’t eat rice grains.

Kalea: That’s tough. That is tough. This is where I personally love working with a collaborative care team. I want the nutritionist on board. I want the health coach on board, because we’re going to have to do some pretty diligent monitoring of both energy intake, macro and micronutrients. So, we might have someone… I just use apps like Chronometer or Chronometer, however you want to pronounce it. I use that app with patients quite frequently. We’re tracking foods, just making sure that we have enough energy. In my practice, it’s fertility-focused. I don’t want someone in a big energy deficit because it can affect ovulation. So, working with that collaborative care team to make sure we’re meeting our micro and macronutrient needs, we have enough energy. It’s going to be so important if we have to restrict like that. It can be done though, right? If we can tolerate starchy vegetables, I’m not sure if that was on the list, but there are ways that we can ensure caloric density, avocados, things like that. But it takes effort and planning.

Dr. Sandi: Sounds good. What about soy? Any issue with organic whole soy?

Kalea: Soy is off-limits on the elimination diet. When we rechallenge, there’s a whole variety of ways. You could do it with soy sauce. You could do it with tofu. You could do it with edamame. So, it’s not part of the three-week elimination. We’re avoiding soy during that time, but then we can rechallenge it. And the thing I’ll say too is if you were to use the Institute for Functional Medicine’s resources, there’s a comprehensive guide that tells you… You know how I showed all those serving sizes? A couple ounces of cheese or two eggs, a cup of whole wheat noodles. There’s a whole strategy in that introduction so you can make sure you’re getting a high enough dose. And so you can make sure that you’re getting a load of soy that will cause a reaction if it’s going to.

Dr. Sandi: A question came in and I’m not sure… It says, “I’d like to know if there’s any reason to know that specific food is causing issues in the gut.”

Kalea: Yeah, like why do I need to know a certain food? I think that’s a good question. Like I said, when we are chronically eating foods over and over that we’re sensitive to, we cause damage at that intestinal barrier, the lining of our barrier, so that we’re increasing intestinal permeability. And so if we lower our exposure to that food, the hope is we have less damage at that intestinal lining, less intestinal permeability, less chronic inflammation, less immune system activation. So, I do think it’s helpful to know if there’s a specific food that you’re reacting to, just so that you can lower your consumption, maybe save it like if it’s, I don’t know, something that’s involved in the recipe that your grandma makes and it’s your favorite, maybe you have it when she makes it on your birthday, but you don’t have it every day.

Dr. Sandi: A question came in and I just want to point out that we are not giving personal health recommendations here. I suggest going to find a practitioner at ifm.org and then working with a health coach as well to help specific dietary needs. So, can we get copies of the sauces you referenced?

Kalea: Oh, I’m happy to share. If there’s a way you all can pass on, I’m happy to share these sauce recipes because they are life-changing, especially the peanut sauce, the dairy-free pesto. Yes, I’m happy to share.

Dr. Sandi: What about any research evidence for the elimination diet? And if so, where can we access that?

Kalea: Oh, Sandi, do you want to tell them about our study that we published?

Dr. Sandi: I was going to save the best for last. Yes. So, we have a randomized control trial that we published in the peer-reviewed Journal of Medicine a year ago and what we did. So, this is something if you are a graduate of our program, member of our alumni program, we match you with a trainee who is going through IFM’s initial course where it is suggested that they personally go on this elimination diet that you’ve just learned about. It can be very hard for these doctors. They may be struggling with it. And this research showed that that group that got the coaching versus the group that just got the standard informational guide, they improved their compliance, particularly those who reported more medical symptomatology. Now, keep in mind, this was a healthy group to begin with. These were doctors, but it was very great results. And so you can reference that study. In fact, we can share that with everybody who’s on the call. Shows the value of working with a health coach as well as the value of an elimination diet.

Let’s see, as we are drawing to a close. So, I would say that… Well, we’ll just get this one, the autoimmune conditions, the autoimmune paleo is sometimes recommended. What are your thoughts about that where you’re eliminating all grains, nuts and seeds, and nightshades? We talked a little bit about nightshades.

Kalea: I think it can be super helpful short term. Again, my goal is always to add back as much diversity as possible. So, I always am hopeful that there’s a reintroduction stage just so the foods that we are tolerating, we can continue to enjoy.

Dr. Sandi: Absolutely. And so if we are non-medical, can we use this, for example, coaches? Yes. So, this is what we teach at FMCA, how to coach the elimination diet. It is a key part of our training where we are teaching you functional medicine principles in functional medicine but in nutrition as well. So, first and foremost, the elimination diet. Well, I want to thank Dr. Kalea for this incredibly informative webinar. And I want to acknowledge everybody who tuned in today. Thank you all for being here. We will continue to have these webinars. So, stay tuned as we bring you more from Functional Medicine Coaching Academy. So, thank you so much.

Kalea: Thanks, everyone.

Dr. Sandi: Bye, everybody.