FOOD INTOLERANCE NETWORK
FACTSHEET
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This page is intended to support people who are following the RPAH (
Your dietitian's booklet will tell you exactly what to eat and how much
to eat of it during your challenges.
The key is to concentrate on one food chemical at a time and to eat lots
of it. As a rule of thumb, 3 days for artificial additives and 7 days for
natural chemicals such as salicylates; however, we find that people may need
longer for bread preservative 282 (5-7 days or more) and at least 10 days for
milk.
The rules of challenge
that your dietitian will recommend are:
·
Several days without symptoms before
each challenge (ask your dietitian – usually it’s 3-5 days)
·
Stick strictly to the elimination
diet. Start again at the beginning (several days without symptoms) if you make
a mistake.
·
Stick strictly to the challenge
foods on your dietitian’s list
Some common mistakes
·
Eat enough foods: at least the
minimum amount of the specified challenge food every day. This is essential.
Especially if you start slowly, you may get confusing results.
·
Eat only specified foods. Foods like
oranges, tomatoes and avocadoes have no place in salicylate or amine challenges
because they contain both.
·
Continue until there is a reaction.
A full seven days is often recommended. However, be realistic. One boy who
broke a window at school during his salicylate challenge was punished severely.
Continuing after you have seen a behavioural reaction may help to identify
other symptoms that may develop (e.g. physical symptoms such as rashes may come
after behaviour) but think about the consequences to the child - you may need
to keep your child at home or stop the challenge early. Some people (e.g. with
arthritis, may need a longer challenge), see Bernard's story on the arthritis
factsheet.
·
No mini challenges except for
babies. Do not give your child one or two serves of one particular fruit and
conclude that "she's OK with bananas" or "apricots don't affect
him". It depends what else he or she eats. Only the most sensitive will
react to a mini challenge. You are looking for the slow cumulative build up of
food chemicals which cause good days and bad days with no obvious cause.
Keep a challenge diary:
this is the diary of a seven day salicylate food challenge with a five year-old
boy who exhibited different kinds of effects - behaviour, rash and bedwetting.
Note that effects can be delayed, occur at different times, build up slowly and
fluctuate. Behavioural reactions depend on the environment so if the child is
getting his own way he will be fine, but when asked to do something he doesn't
like, he will overreact. From story [446] on www.fedup.com.au
Day
1 - No reaction
Day
2 - Tantrum, kicking, punching (wanted more
peppermints)
Day
3 - Punched a peer's arm at kindy
Day
4 - Itchy rash appeared on inside of elbow
Day
5 - Well behaved
Day
6 - Red blotches and pimples all over lower half of
face, tantrum, screaming and hitting me (didn't want photo taken)
Day
7 - More blotchy and spotty, face sore and raw. [End of
challenge foods]
Day
8 - Wet bed
Day
9 - Wet bed, sore tummy, sore red anus, constipated
Day10
-Wet bed, kindy complained of very small attention span, loss of concentration.
Day11
- Face clearing, no wet bed, generally seems to be getting better
Day12
- wet bed again.
By the end of your elimination diet, you must know whether you are
sensitive to salicylates and amines. Otherwise you may be restricting healthy
foods unnecessarily. If you are avoiding dairy foods, wheat or gluten, the same
applies. Very sensitive people and young babies need not challenge. Reactions
to small amounts of salicylate or amine containing foods will already have been
obvious.
It is easy to make mistakes during challenges. The worst case scenario
is an inconclusive result. People at teaching hospitals will get capsule
challenges which are quick and obvious. Others do food challenges. Most people
enjoy the salicylate and amine challenges, at least until reactions start. Don’t
expect immediate reactions. People are different. Some reactions build up
slowly and some reactions are very delayed.
Types of food reactions
·
Same day: can occur almost
immediately or within a few hours and last a few hours
·
Next day: can start the next day and
last for a whole day
·
Slow reaction: can build up slowly,
sometimes worst on the third day, then slowly improving – it can take a week or
up to a month for effects to fully disappear. Children who take a month to
completely recover can be extremely difficult to work with because can appear
to have recovered but may flare up again if there is a negative interaction.
Artificial colours and MSG
are often a same day reaction, preservatives a next day reaction, and salicylates
or amines a next day or slow reaction, but everyone is different. Expect
anything. Timing also depends on the size of the dose.
If you pass the challenge
Most people assume they can
add challenge foods back into their diet as soon as they pass a challenge.
However, so many people make mistakes when doing this - such as thinking 'I
don't react to salicylates so I can eat broccoli again' although broccoli
contains both salicylates and amines (I did this!) - it is better to finish all
your challenges before reintroducing the food chemicals you can tolerate.
Salicylate challenge
None of the very high
salicylate foods (tomato sauce, broccoli, oranges, your favourite lasagne recipe)
are suitable for the challenge because they all contain amines as well. Some
people get inconclusive results from their challenge because they expect
salicylates to be like food colours, one big dose and you see a big reaction,
but it's not like that. Salicylates are eaten many times a day every day and
reactions can build up slowly to have the same effects as food colours.
Your dietitian will tell you
to eat a certain number of serves per day of the following foods. It is
important to eat as much as possible. One serve equals approximately one cup.
It is best to use more high salicylate foods (capsicum, corn, cucumber,
zucchini, Jap pumpkin, Granny Smith apples, apricots, guavas, peaches,
nectarines, cherries, strawberries, rockmelons, watermelons) than moderate
salicylate foods (mango, asparagus, carrot, butternut pumpkin). You can also use spices such as cinnamon or
curry-type spices (turmeric, cardamom, coriander, cumin, garam marsala, ginger,
paprika, pepper) in powder form - not curry paste that can contain colours or
synthetic antioxidants; honey, preservative-free
apple juice and peppermint tea. Use salicylate options in recipes and see
salicylate challenge recipes in the Failsafe Cookbook and Fed Up. It is
important to eat the highest dose of salicylates you can, right from the start.
Salicylate challenge story 1: ‘Of the
foods listed we ate tinned apricots (heaps) in syrup on our rice bubbles,
preservative-free apple juice, curries or pumpkin soup for dinner and only
vegetables recommended for the salicylate challenge. We put away mountains of
carrots and similar of grannies in a week as well as large quantities of
pumpkin, kumara, corn, capsicum (had forgotten how good that tastes), cucumber,
curry, cinnamon, tea and everything else we could find in season that was on
the list.
‘We went for about the first three days with no
reaction at all. Everyone seemed to respond differently. My husband and one son
seemed not to react. My 8 year old son - the reason we started this thing -
became fractious and difficult and seemingly continuously involved in conflict
with his brothers and sisters, pretty well back to pre-elimination behaviour.
Yuk! The youngest two had wet beds and seem a bit anxious and grumpy. I have
probably had the most obvious reaction. My flesh felt like it was crawling, my
eyes were stingy, I was tired and grumpy. I also had bloating and tummy aches
and alternating constipation and loose stool. I got restless legs so badly
while I was trying to fall asleep that I would nearly jump off the bed.’
Reader, by email.
Salicylate challenge story 2: 'I found the
salicylate challenge really difficult. Even though salicylates have the worst
effect on my children, it took me over a year to work that out because they are
delayed responders and the reactions are irrational fears and social withdrawal
- not what I had expected'.
Amine challenge
Your dietitian will probably tell
you to eat a certain number of ripe bananas and dark chocolate every day for seven
days. It would be less for small children. Amine reactions are usually delayed
up to several days or more. For dark chocolate you can use commercial dark
chocolate bars or Nestle dark chocolate choc bits. For children who don't like
dark chocolate - although most do after three weeks on the elimination diet -
you can cook the choc bits into chocolate cake or banana muffins, or freeze the
bananas and process into banana icecream topped with melted chocolate, see
recipes in the Failsafe Cookbook.
You can also eat as much as
you want of: canned tuna, salmon, sardines, frozen fish, seafood except prawns,
pork chops and roast pork (but not bacon and ham with preservatives) or homemade
gravy (see recipe in the cookbook). In my experience, and research supports
this, amines can be associated with aggression and conduct problems in some
children. Consider keeping children with a potential to react like this at home
for the amine challenge (and preferably for all challenges). You can use an
antidote as soon as you are convinced there is a reaction, but you need to keep
noting effects in your diary - some children take up to a week or even a month
to recover from the amine challenge, with increasing good days punctuated by
occasional outbursts.
If you react to both salicylates and amines …
·
Once you are convinced there is a
reaction, you can use an antidote (look under Antidote in the index of any of
my books), although it will only help for an hour or two
·
People who react to both salicylates
and amines can stop challenges now as they will probably react to additives as
well, although it is worth doing some challenges, see below
·
It is useful for asthmatics to
identify which additives are associated with their asthma - e.g. sulphites,
benzoates - but this should be done supervised by your dietitian
If you have passed salicylates
or amines, it is worth doing the rest of the challenges. Some people react only
to one or two additives, yet if they eat them every day the result is the same
as for a person who reacts to everything.
Dairy and wheat challenges should be done at some stage
if you are avoiding these.
·
Your dietitian will probably recommend
at least one cup of milk every day for a week. In our experience, ten days is
better, as this can be a slow reaction. We recommend the same for A2 milk, in
our experience, it's worth challenging A1 and A2 milk separately. A2 milk
(www.A2australia.com.au) is sometimes better tolerated by people with food
intolerance.
·
Your dietitian will probably
recommend a serve of plain uncoloured pasta plus a certain brand of plain wheat
crackers (no hidden antioxidants!) every day for a week for the wheat
challenge. Note that bread is not suitable for a wheat challenge because
it contains so many other ingredients. If you pass your wheat challenge, you
may still need to consider wholegrains. Many people find they can manage
refined white flour products such as bread and pasta but wholegrain wheat
products affect them. This has been implicated in everything from behaviour to
irritable bowel to psoriasis. You can try at least 4 wholegrain biscuits such
as VitaBrits or Weetbix per day as well as wholegrain flour, pasta and
wholemeal failsafe bread for three days or more.
Bread preservative (282)
is worth challenging because it is often eaten unknowingly every day in a
healthy food and some people are so badly affected. Although the label may list
preservative, the dose can vary especially in winter. In our experience it is
best to continue for a week if you don’t see a reaction within a few days. Eat
as much preserved bread, crumpets and/or English toasted muffins per day as you
want – at the very least a few slices per day.
Annatto colour (160b)
is worth challenging because it is in so many foods labelled 'all natural'. Many
failsafers report reactions from vanilla yoghurt coloured with annatto (try it
several days in a row. If dairy free, look for soy yoghurt with annatto, or the
Sanitarium So Good Bliss vanilla icecream. Some custard powders also contain
annatto. If you see a reaction, please report it to us! (suedengate@ozemail.com.au)
Sulphites (220-228)
- sulphites are the additive most likely to affect asthmatics, but they are
also associated with the complete range of food intolerance symptoms including behaviour.
Some people are very sensitive to even tiny amounts. Most foods which contain
sulphites (eg wine, dried fruit, sausages, fresh grapes) also contain
salicylates or amines so it is best to do those challenges first. WARNING If
you are an asthmatic, don't do this challenge without supervision by your
doctor or dietitian as it can be rapidly life-threatening, even if you've never
noticed a reaction before. See reader experience below.
Sulphite challenge story:
"Our food journey all started with me picking up your Fed Up with Asthma
book from the bookstore after our four year old had just experienced a bout of
wheezing. I read it all in one sitting and was left both horrified and hopeful.
We decided that since we had nothing to lose that we would try the diet as a
family in an attempt to pinpoint the trigger of our daughter's asthma. I was
optimistic about finding a trigger but not really expecting to find it. Grace
did the sulphite challenge with an apricot fruit bar as recommended by our
dietitian (she had no reaction to the salicylate or amine challenges) that I
gave her at the start of a short car journey. Within 5 minutes of finishing the
bar, her breathing had become so laboured and wheezing so loud that I had to
stop the car to give her Ventolin.
Over the next few months I repeated
the challenge with a different brand of fruit bar, berry flavour and again with
4 dried apricots. The same results each time. Prior to the diet she would eat
dried fruit, sausages and non-organic grapes quite often and was on a
substantial twice daily preventer medication regimen as well as Ventolin about
1-2 times per week. Funnily enough it had never occurred to us that ‘healthy’
food could possibly trigger asthma."
Benzoates (210-213) If
you think lemonade is a relatively safe drink for your failsafe child at parties,
it’s worth doing this challenge. It’s also worth doing because sodium benzoate
(211) or other benzoate preservatives are used in most medication for babies
and children. At the time of writing, Schweppes canned lemonade contains
benzoates but the bottled lemonade is preservative-free but this can change –
read the label. You can try several cans of lemonade per day for several days.
Antioxidant challenge
·
Gallates (310-312)
·
TBHQ, BHA, BHT (319-321)
This challenge is definitely
worth doing because these additives are often unlisted. Your dietitian may
recommend a particular brand of cooking oil or margarine. These change
constantly so check the label. At the time of writing, McDonalds fries contain
BHA 320 and could be used as a challenge but you would need to check this first
on their website, as ingredients change frequently. Many failsafers have been
tripped up by assuming hot chips are a safe snack when shopping because they
haven’t seen a reaction after one dose. You need to know what to expect if your
child eats synthetic antioxidants every day for three or four days – kids love
this challenge. Please report reactions to us!
Sorbates (200-203) – This challenge is worth doing
because many families noticed reactions when sorbate preservatives were first added
to cream cheese. You can also use Philly preserved cream cheese in the tub but
not the packet (read the label). As it is the kind of item often used every day
e.g. in sandwiches, and the reaction can be a slow build up, you could try
normal serves every day for a week or extra high doses (e.g. in a home-made cheese
cake) for a few days. Please report reactions to us!
MSG (621 and natural
glutamates) – your dietitian’s booklet will probably
recommend soy sauce with meals, although I have heard of a dietitian suggesting
MSG powder such as Ve-tsin from Chinese groceries. We find that many people can
manage the small amounts in green peas, even if they react to large doses of
MSG. For a green pea challenge, eat green peas twice a day every day for three
days. If no reaction, you can add peas back into the diet.
Flavour enhancers 635, 627
and 631 also called ribonucleotides, disodium guanylate and disodium
inosinate - if you don't react to anything else, you could still be affected by
these additives, see the Ribo Rash factsheet. We
don't recommend challenges because some people never recover. If you eat any
product containing these additives, look for possible reactions for the next 48
hours, and understand that reactions are related to dose - if you don't react
to a small amount, you can still be affected by a larger amount. This new
additive has been associated with everything from behaviour problems to anxiety
and heart palpitations and many people develop an unbearably itchy rash and/or
swelling of the lips, throat and tongue. To see if you are affected by these
additives, it is best to keep a detailed diary of food and reactions.
Nitrates (249-252) –
your dietitian will probably recommend processed meats such as ham or bacon.
Not for amine reactors. Check that the ham or bacon contains only nitrates, not
sulphites or flavour enhancers as well. We don’t recommend this challenge
because when eaten frequently, nitrates are a known carcinogen (cancer-causing
agent). Even if you pass this challenge, it is best to limit your intake of
nitrates.
Sugar - This challenge is optional. It is for people who
are convinced their children react to sugar. In nearly all cases, this will be
due to salicylates or additives. However, there are a very few extremely
sensitive people who do react to white sugar. You need to test this with a
challenge. Eat 10 sugar cubes and observe reactions. If no reaction, double the
amount.
Fish oils, supplements and other foods - You can
choose to challenge anything you want, from favourite foods to herbal or
nutritional supplements. Just follow the rules of challenge. My children chose
Mars bars - one a day every day for three days - and failed.
After challenges, what's your tolerance?
Your dietitian will probably suggest
very careful gradual reintroduction: for example, half a cup or less of moderate
salicylate foods (e.g. carrots or butternut pumpkin for salicylates) every two
or three days for a few weeks, then every day for a few weeks; then increasing
the dose and so on. As usual, keep a diary! When you start reacting, you go
back to the previous level. This is where a lot of people come unstuck. They keep
on adding salicylate-containing foods until the levels are quite high, then six
months or a year later, they say ‘the diet isn’t working as well as it did when
we first started.’ Effects can sneak up on you. If the diet isn’t working as
well as you’d like, you can go back to low salicylate foods and keep the rest
for holidays when your tolerance is higher due to lack of stress.
Reader comment:
'I am at the stage now where I have reintroduced amines [e.g. bananas, tinned
tuna] into my diet about twice a week, with the exception of my premenstrual
week. I am prone to being over confident and blowing my reintroduction from
time to time but I have pretty much worked out the timing and culprits'. -
reader, NSW
The
information given is not intended as medical advice. Always consult with your
doctor for underlying illness. Before beginning dietary investigation, consult
a dietician with an interest in food intolerance. You can find a supportive
dietitian through the Dietitians Association of
© Sue Dengate update February 2008
