Welcome to episode 483 of The Whole View! This week, Stacy and Dr. Sarah break down the science of reintroductions commonly associated with the AIP to determine how they work and how they might benefits us.
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The Whole View, Episode 483: Reintroductions—They’re not just for AIP
Welcome to episode 483 of the Whole View! (1:20)
This Week’s Listener Question:
What foods have you been able to reintroduce, Dr. Sarah? What are common foods that people succeed with?
I’ve been working with the AIP for a little over a year now, and the autoimmune community is so supportive and helpful with eliminations. Now that my doctor and I have made so much progress with correcting my dysbiosis, its almost time for starting the reintroduction process, but nobody talks very much about this part!
For me, I’ve been reacting to almost everything that’s removed on the AIP and the crucifer and umbellifer families besides. I want to know what others have successfully reintroduced but there’s not much talk about that online.
I know that every body is different, but how much can someone expect to expand their diet? What are the areas that most people have trouble in? Reintroduction feels lonely right now!
The 3 Phases of the AIP
Stacy and Dr. Sarah talked about this in TPV Podcast Episode 377: Common Misconceptions about the AIP.
Many people refer to the Autoimmune Protocol as merely the first phase of this approach, also termed the Elimination Phase (like most AIP leaders, Dr. Sarah, too, is guilty of using the term AIP as a shorthand for AIP Elimination Phase).
The term Elimination Phase can be misleading because AIP puts a humongous amount of emphasis on nutrient density.
It’s also a holistic approach to health, including a strong focus on getting adequate sleep, managing stress, nature time, connection, social networks, and living an active lifestyle while avoiding overtraining.
The Reintroduction Phase is your opportunity to truly understand your body’s needs, identify your trigger foods, and hone in on your personalized optimal diet for lifelong health.
After some time, many (if not most) of the excluded foods, especially those that have nutritional merit despite also containing some (but not too much) potentially detrimental compounds, can be methodically challenged (where you test your tolerance to them) and reintroduced (where they make their way back into your regular diet).
The Maintenance Phase
Autoimmune Protocol provides a framework for a health journey full of self-discovery.
The goal is to discover your own personalized maintenance diet and lifestyle, defined as that collection of choices that keeps you healthy and you feel you can sustain over the long term.
Dr. Sarah likes to think of the Maintenance Phase as the empowerment that comes with having discovered your food triggers (the lines you can’t cross), what your body needs to thrive (your optimal choices), and what your body tolerates (your wiggle room).
Reintroductions Aren’t Just for AIP
An elimination and challenge protocol (which is really what we’re talking about when we say “reintroductions”) is the gold standard for identifying food allergies, sensitivities, and intolerances. So, this isn’t just helpful for people on the AIP, but everyone is looking to understand better how their bodies are reacting to foods.
Even if you do allergy or food sensitivity testing, it’s recommended to follow up with elimination and challenge to verify results!
These tests have about a 10% false-positive rate and a 30% false-negative rate.
How Elimination and Challenge Protocols Work
Identifying a link between specific foods and how we feel can be tough when we’re chronically exposed to those foods for a variety of reasons:
We adjust to how bad we feel, making it difficult to realize that we don’t feel our best.
Our bodies can upregulate protective mechanisms, like producing more mucus in the gut, restraining reactions to the degree that makes them difficult to recognize.
Symptoms can be amorphous—like feeling tired or moody—and we may not experience them immediately the following consumption.
Elimination and challenge protocols remove all these limitations, which makes it easier to identify personally problematic foods.
Cutting Out Food
Cutting out the foods we may be reacting negatively to gives our bodies time to detoxify and recover from any negative health impacts.
Many people express feeling renewed energy and well-being after adopting a Paleo or AIP diet, typically within a couple of weeks.
When you’re feeling great, it’s easier to identify that you don’t feel your best when a challenged food causes symptoms, even if those symptoms are fairly mild.
The elimination phase also allows for the downregulation of any protective mechanisms, which means reactions are sometimes exaggerated and obvious when we consume foods that don’t work for us.
Finally, a systematic challenge protocol allows us to identify problematic foods even when our symptoms are vague and occur days after consuming those foods.
Stacy and Dr. Sarah talked about how we can have exaggerated reactions to eliminated foods upon challenge or exposure.
- TPV Podcast Episode 241, Can You Create or Prevent a Food Allergy?
- TPV Podcast, Episode 295: Can Food Intolerances Be Fixed?
Exaggerated reactions typically occur in the case of food allergies and intolerances.
The mechanisms behind these exaggerated reactions are exactly why elimination and challenge diets are the gold standard for identifying food sensitivities.
Even in a perfectly healthy gut, food-protein, several different cells absorb, process, and then present antigens to the immune system via a process called antigen presentation as part of the body’s constant patrol for infectious agents.
A type of sentinel immune cell in the gut called dendritic cells stick a long, armlike protrusion, called a dendrite, between enterocytes and into the lumen (inside) of the gut to “sample” the gut environment in search of infection.
They then migrate to the gut-associated lymphoid tissues to present the antigens they’ve found (antigens from invading pathogens or food antigens) to other immune cells (naïve T cells and B cells).
Immune Reactions with Reintroductions
If your cells recognize these antigens, they ramp up a response.
BUT regulatory “T” cells of the adaptive immune system mediate immune tolerance.
These cells can suppress the activity of those cells propelling an immune response to a food antigen (Th1, Th2, and memory cells) by producing anti-inflammatory cytokines (chemical messengers) that inhibit immune-cell activation, or they can actually cut the receptors off of immune cells so that they can’t bind to the food antigen.
But here’s the kicker: these regulatory cells tend to have a shorter lifespan than the immune cells (there may be a genetic factor at play here since the lifespan of these cells can vary from a few days to months).
If you have an immune reaction to a specific food, there is the period after eliminating it when the immune cells responsible for the reaction are still hanging around. Still, the regulatory cells responsible for immune tolerance are too low in number to constrain the reaction.
This is a loss of immune tolerance, and it is one cause of the exaggerated response to a challenging food.
Immune tolerance is generally considered a good thing, but, of course, if you don’t have an immune reaction to a food, you don’t need to develop immune tolerance to it.
The mere act of restoring healthy digestion can make many food sensitivities disappear.
Immune tolerance also relies on how much of an antigen crosses the gut barrier because memory cells tend to reside over the long term in the spleen.
In the case of a leaky gut, much more of a specific food antigen can cross into the body than when the gut barrier is intact, getting into the circulation where the food antigen can activate memory cells in the spleen, stimulating an immune response.
Once you have a healthy gut barrier, the “sampling” of antigens becomes a much more tightly controlled process, and antigen is unlikely to get into the circulation.
When to do Reintroductions on AIP?
There are no hard and firm guidelines on when to reintroduce foods on the Autoimmune Protocol.
Dr. Sarah has always been hesitant to put a firm time frame on when to try reintroductions. There seems to be fairly large variability in how quickly people experience symptom improvement when they first adopt the Autoimmune Protocol.
This is likely related to disease activity, genetic risk factors, nutrient deficiencies, digestion efficiency, underlying challenges, and specific implementation of the AIP diet and lifestyle).
As long as you see improvements in your health thanks to your diet and lifestyle changes, you can try some reintroductions after three to four weeks.
If you aren’t seeing improvements after following the Elimination Phase of the AIP for 3 to 4 months, consider working with an AIP Certified Coach or functional medicine doctor to troubleshoot, rather than continuing to bang your head against the proverbial wall.
The Reintroduction Procedure
Methodical is the name of the game.
In general, reintroduce only one food every five to seven days, and spend that time monitoring yourself for symptoms of a reaction.
It’s best to keep a food and symptom journal during this process, too: the reaction to some foods builds over time, and it can be difficult to identify the culprit without this record to review.
Don’t reintroduce a new food if you have an infection, have just had an unusually strenuous workout, got less sleep than normal, are feeling stressed, or are under any other circumstances that may make interpreting a reaction difficult.
Some foods you reintroduce you’ll end up regulating to “sometimes foods.”
Sometimes food doesn’t cause a reaction when you consume it occasionally, but that can subtly undermine your health (even if simply by displacing more nutrient-dense options) if you consume it regularly.
A thorough understanding of why you eliminate each food on the AIP is helpful for sometimes determining foods versus everyday foods – which is why Dr. Sarah teaches her class.
The Reintroduction Procedure
Select a food to challenge. Be prepared to eat it two or three times in 1 day, then avoid it completely for a few days.
The first time you eat the food, eat half a teaspoon or even less (one teensy little nibble). Wait fifteen minutes.
If you experience any symptoms, don’t eat anymore. If you don’t, eat one teaspoon of the food (a small bite). Wait fifteen minutes.
That’s it for now. Wait two to three hours and monitor yourself for symptoms.
If you still haven’t experienced any symptoms, eat a normal-sized portion of the food—either by itself or as part of a meal.
Do not eat that food again for 5 to 7 days, and don’t reintroduce any other foods during that time. Monitor yourself for symptoms.
If you have no symptoms during the challenge day or at any time in the next 5 to 7 days, you may reincorporate this food into your diet.
Symptoms to Watch For with Reintroductions
Symptoms of a reaction aren’t always obvious, so keep an eye out for any of the following:
- Any symptoms of diagnosed disease returning or worsening.
- Gastrointestinal symptoms: tummy ache, heartburn, nausea, constipation, diarrhea, change in frequency of bowel movements, gas, bloating, undigested or partly digested food particles in stool
- Reduced energy, fatigue, or energy dips in the afternoon, or a second wind in the late evening that makes it hard to go to sleep at a good time
- Cravings for sugar, fat, salt, or caffeine
- Pica (craving minerals from non-food items like clay, chalk, dirt, or sand)
- Trouble falling asleep or staying asleep, or just not feeling well-rested in the morning.
- Headaches (mild to migraine)
- Dizziness or lightheadedness
- Increased mucus production: phlegm, runny nose, or postnasal drip
- Coughing or increased need to clear your throat
- Itchy eyes or mouth
- Aches and pains: muscle, joint, tendon, or ligament
- Changes in skin: rashes, acne, dry skin, little pink bumps or spots, dry hair or nails
- Mood issues: mood swings, feeling low or depressed
- Feeling anxious, less able to handle stress.
Suggested Order of Reintroductions
Meghan asked about what is most likely to be successfully reintroduced, and that’s where my suggested order of reintroductions comes in.
There is no right or wrong way to choose where to start when it comes to food reintroductions.
A very good argument is that the first foods you reintroduce should be the ones you miss the most. Another argument for reintroducing the foods is that they are least likely to cause a reaction or have the most redeeming qualities.
The following suggested order of food reintroductions considers both the likelihood of reaction (based on what science says about how that particular food interacts with the gut barrier or the immune system) and the inherent nutritional value of the food.
The first stage includes foods that are most likely to be well tolerated or are the most nutrient-dense.
- egg yolks
- fruit-, berry- and seed-based spices
- seed and nut oils
- ghee (from grass-fed dairy)
- occasional coffee
- cocoa or chocolate
- peas and legumes with edible pods (green beans, scarlet runner beans, sugar snap peas, snow peas, etc.)
- legume sprouts
The second stage includes foods that are less likely to be well tolerated or are less nutrient-dense.
- chia seeds
- coffee daily
- egg whites
- grass-fed butter
- alcohol in small quantities
The third stage includes foods that are even more unlikely to be well-tolerated but still have compelling nutrition.
- sweet peppers
- peeled potatoes
- grass-fed dairy
- lentils, split peas, and garbanzo beans (aka chickpeas)
The fourth stage includes most likely untolerated foods that you may wish never to challenge.
- chili peppers and nightshade spices
- unpeeled potatoes
- alcohol in larger quantities
- gluten-free grains and pseudograins
- traditionally prepared or fermented legumes
- white rice
- foods you are allergic to or have a history of strong reactions to
Don’t Be Afraid of Food Reintroductions!
In her last session of the AIP Lecture Series, Dr. Sarah had quite a few students who came to my class, having tried reintroductions in the past and having every or most food not work.
This is a little beyond Meghan’s question, but Dr. Sarah can share that every one of those students felt ready to tackle them again after taking her class.
But, the most common thing Dr. Sarah sees is a fear of reintroductions. Don’t be afraid! While a successful reintroduction is fantastic, even a failed one gives you valuable knowledge to help you navigate future situations!
- TWV Podcast Episode 411: Do we still follow the Paleo diet?
- TWV Podcast Episode 466: Our Stories on the Healing Power of Food and Ditching Diet Culture