Bates' Elimination Diet (22 pages of text, 224KB .pdf)
In the April 2006 Townsend
Letter, along with David
Fairbrook, MD, I reviewed
fibromyalgia (FM) to immune injury or
hypersensitivity. This sequel is meant to offer practical advice
based on clinical experience rather than the literature. Since 1985,
run over 10,000 patients through elimination diets. In 1999, we noted
that FM patients were benefiting the most from these diets, and since
then, we have focused exclusively on those patients. Although FM
patients have taught us that elimination diets have great potential
FM, these patients have a variety of special needs that must be addressed
before an elimination diet will help the majority of them. The following
considerations should provide 80% or better reduction in patient
symptom ratings, on a sustained basis for at least 60% of those patients
complete the three-week regimen.
Patient Selection Criteria
Many FM treatment candidates present on
a dozen medications with some prescriptions for the purpose of treating
the side effects of other
medications. These present a great challenge. FM patients are so
hyper-allergic, they often suffer especially severe drug side effects,
and their FM symptoms are also triggered by many supplements. By
the time they are deep into polypharmacy, drug reactions can block
the benefits of allergen elimination, and alternatively, drug withdrawal
effects can render them unwilling to continue treatment before they
can benefit. On the other hand, successful FM patients usually present
on Selective Serotonin Reuptake Inhibitors (SSRIs), narcotics, migraine
and GI tract remedies, handfuls of supplements, and other potential
FM triggers. They are encouraged to temporarily discontinue any supplements
that they don't absolutely need to avoid suffering in the short
term and to stay on their medications, slowly discontinuing each
one as they experience remission of each symptom set. Patients are
warned to avoid narcotic rebound pain and withdrawal by tapering
down the dose long after the pain is gone.
SSRI withdrawal is a challenge for clinician and patient alike. We
wait until the patient has long stabilized in symptom remission and
only attempt the withdrawal
after educating and preparing the patient through helpful books and web sites.
The "bolts of lightning in the brain" reported by patients trying
to gradually taper off SSRI medication (Zoloft comes to mind here, especially)
seem to be largely ignored by the literature and pretreatment PCP warnings,
but this phenomenon is very real, day to day, as we attempt to help people
discontinue these perhaps underestimated medications.
Prednisone has shown the ability to entirely sabotage the benefits of allergen
elimination in about 30% of cases. It is a risk factor worth sharing with patients
who might elect to try the treatment anyway and, if unsuccessful, come back
to the treatment at a later date when they have discontinued prednisone.
Patients with childhood trauma and chaotic lives of anxiety and compulsive
smoking, eating, drinking, or drugging, are usually going to be overwhelmed
and drop out of treatment in the first week. They should not attempt elimination
dieting without a support network of peers and counselors, as well as contingency
plans for dealing with the challenges of early abstinence. Even the compulsive
eater with such a history should be treated with grave reservations, caution,
and the expectation that they will need extraordinary support.
Patients who are looking for a miracle medication will be wary, skeptical,
and quick to run away from what seems to them like a flaky and low-tech treatment.
Save their time and yours by requiring front-end education and, ideally, having
them embedded in a support group of FM peers inspired by members who have already
experienced success. These groups have tended to produce stunning adherence
rates with as many as 90% of patients in a group clearing symptoms and completing
a several months-long maintenance regimen. Relying on one-on-one consultations
in the examining room produces dismal adherence by comparison. Offered the
treatment cold, with no educational preparation, about 15% say "no thanks," and
at least 30% never fully engage in the treatment or drop out early during the
difficult first week. We offer an educational patient DVD, gratis, which you
are encouraged to copy and distribute, perhaps as a pre-treatment educational
Another front-end obstacle exists for the patient who has tried elimination
dieting in the past without success. A close look at what happened may reveal
that vitally important elements were lacking, and a case could be made for
trying this targeted FM-driven method.
The Heart of the Treatment Dilemma
A standard elimination dieting protocol
is going to fail more than half of FM patients for at least one of
three reasons: 1) The patient often experiences
a severe flare of all FM symptoms in the early days. This is considered an
allergen withdrawal effect: a rebound spike in immune dysregulation. During
the first three days of withdrawal, safe foods are often experienced as revolting
and nauseating, and they do not satisfy a craving for allergenic foods disguised
as unrelenting hunger. This early crisis is exceptionally discouraging in
FM, and patients need close support until it is resolved; 2) The patients' hypersensitivity
via multiple metabolic pathways means that some foods that tested safe in
an IgG ELISA panel, will trigger FM symptoms, as will a food or two deemed
generally hypoallergenic by diet authors. For instance, rice is the least
allergenic grain, but 15% of our FM patients react to it. This pattern persists
even with the exclusive use of organic foods; 3) By the seventh day of elimination,
withdrawal effects have faded, to be replaced by a newfound hypersensitivity
to remaining FM trigger molecules in the bloodstream. This is when imperfections
in the supposed hypoallergenic food list prevent progress and, more importantly,
inhalant FM triggers come to the forefront.
It cannot be overemphasized that the primary cause of failed elimination
diets in FM is the lack of an exhaustive inventory of inhalant triggers in
life and the management of exposure to them. This is an area where knowledge
of the most notorious inhalant FM triggers is vital, yet often unrecognized
or underestimated by patients. The problem of medication or dietary supplement
FM trigger effects also shows itself at this time.
The Heart of the Solution
Because of the above complications, no elimination
diet protocol is going to deliver results consistently without trial-and-error
along the way, especially in the second week when FM patients get "stuck," due
to continued FM trigger exposure in foods, drugs, and the environment.
Our patients go to an Internet workstation every night where they
rate the severity of each symptom for the last 24 hours. These numerical
electronically totaled, and the daily score is graphed. When the graph goes
up, symptoms are flaring. Most graphs show a spike during the early days of
withdrawal. We know that the spike should resolve into a steep clearing trend
by the tenth day if we have the right combination. This is such a robust phenomenon;
a horizontal plateau graph on day ten almost always means that a hidden trigger
is at work which must be identified and removed for remission to take place.
The graph is so necessary to this endeavor that we can have no opinion about
what the patient should do next if we can't see their up-to-date symptom
scores generating a graphed profile.
These symptom graphs tend to cluster into a few categories in the second week.
Some profiles suggest workplace toxicity, while others reveal the home to be
the worst offender. The profiles also imply different patient types in terms
of internal variables and lead to interventions suited to their needs.
The software that facilitates symptom tracking also streamlines support and
supervision. The clinician can review dozens of graphs in a few minutes and
mouse clicks. This daily review is useful during the withdrawal crisis when
patient support and encouragement is so necessary and in the second week, during
which all troubleshooting decisions are determined by the symptom severity
graph. After that, symptoms begin disappearing, and this less intense maintenance
phase requires far less Internet supervision. The clinician's software
facilitates automated email communications with the patient, so an intervention
consists of glancing at a graph, noting the situation, and then typing a few
words in a box and hitting "Send."
We have been using this web-based system to lead Internet patients through
the process for about ten years, no matter where they may live. These distance
patients, scattered between many continents, have tended to do better than
clinic patients, probably because their self-selection created a group with
more initiative, savvy, and determination than average.
Since the symptom severity graph is driving all the decisions along the way,
our printed treatment protocol readings for each day include advice such as, "what
to do if your graph is…" and what that graph result means. This
advice feature has enabled many patients to operate independently with "artificial
intelligence" that can adapt to their changing needs. Again we wish to
share, gratis, the written protocol and Internet workstations for both patient
and clinician, believing these to be worthwhile elements in making elimination
diets more effective in treating FM. Perhaps such collaboration could decrease
the pathos and abject suffering of those FM patients who are amenable. You
can try the symptom rating system at www.beyondfibromyalgia.com by clicking
on "ten minute assessment."
Since 1985, treatment failures have proved
illuminating. As enumerated above, adherence breakdowns constitute
the majority of failed treatments,
and this is the area where the clinician's anticipation and
resolution of problems can make the most difference.
Among the patients who adhere assiduously to all treatment instructions,
there is a subgroup of determined people who "took it to the limit" without
success. These exemplary hard workers tend to stay in touch after we have given
up hope of helping them, and they have taught us much. These patients fall
into two groups. One small group remains so hypersensitive to inhalant toxins
and allergens that they are buffeted by Multiple Chemical Sensitivity (MCS)
attacks almost anywhere they go. Deep detoxification would be their best next
step. The larger group of treatment failures are people who cannot afford to
quit their job in a toxic "sick building" and can't benefit
from activated charcoal air cleaners because they must move around to do their
work duties. Others are too poverty-stricken to move out of a rental home with
toxic mold or leaking natural gas furnaces and water heaters, or perhaps an
older house trailer contaminated by urea formaldehyde pressboard.
Many patients owe their symptom remission to never straying far from their
air cleaners. This issue deserves discussion. Not all air cleaners are equal.
Ozone generators, if strong enough, are good for killing off molds and speeding
the curing of fresh carpets, paint, etc. We have an industrial strength ozone
generator we use as a clinic loaner, but patients are recommended to re-enter
the home only after the unit is turned off and the space aired-out. Pyramid
sales organizations selling air cleaners combined with ozone generators are
regarded as part of the problem, not the solution. We recommend that patients
remove their pets and even houseplants from the home before treating it with
If an air cleaner does not contain pounds of activated charcoal, it is incapable
of scrubbing out the petroleum distillate fumes that, ounce for ounce, are
a thousand times more harmful to FM patients than mere inhalant allergens.
We started out in the mid-1990s recommending Austin Air units to our patients.
Their units have saved lives, but we ran into some problems. Their "plus" line
of treated filters (paradoxically intended for MCS customers) tend to spark
symptoms in our most sensitive patients. Their basic zeolite-activated carbon
is toxic to a tiny percent of our hyper-MCS patients, so we started special
ordering their more expensive coconut-activated charcoal filters, which served
better. Aireox air cleaners (Aireox.com) have performed admirably. We view
their filter technology as state-of-the-art in MCS and FM treatment. Aireox
also have the exclusive answer to the problem of auto travel exposure with
a 12-volt unit that plugs into cigarette lighter receptacles and delivers excellent
performance. These days, we often tell patients that they cannot hope to get
well without an activated charcoal air filter, and we recommend the Aireox
D-45. Several web sites sell these units at bargain prices.
Back to Treatment Failures and Lessons
One patient who never experienced the slightest improvement in symptoms with
us, subsequently tested positive for Lyme Disease, but has yet to benefit
from its arduous treatment after almost a year with another provider. This
patient has introduced us to a Lyme information subculture that has promise
and deserves study. Another hard-working patient embarked on an exhaustive
Candida Albicans treatment using multiple fecal cultures experimentally dosed
with many drugs and other remedies. After suffering side effects from a wide
variety of rotated antifungal drugs and botanicals for months, she achieved
remission of FM symptoms.
One spectacularly determined Internet patient achieved about 50% remission
of FM, MCS, and rheumatoid arthritis (RA) symptoms using our methods, but could
go no further. She embarked on a regimen with a Boise, Idaho physician, Dr.
Thornburgh, DO, who used a set of more sophisticated treatments we barely comprehend
to achieve 90%+ remission. This lesson has reminded us that clinical interventions
that might be derided as metaphysical by some should not be too quickly dismissed.
Other patients have achieved additional relief from Hubbard-style sauna heat/sweat
detoxification. Detoxification of retained and sequestered insecticides, heavy
metals, and other toxins is probably the most elegant key to the FM treatment
solution in most patients, operating at a deeper level of the illness. Since
our Townsend Letter paper was published,
we have received letters from noted practitioners in many locations who report
excellent FMS treatment results
from various detoxification techniques. We would view elimination diets and
air quality control as a "quick fix," providing most patients with
a level of symptom remission that they should then consolidate and sustain
indefinitely with detoxification.
Our treatment failures teach us that many of our colleagues have the sophistication
to help patients we cannot, and we especially hope to improve our understanding
of detoxification with their help. On the other hand, our successes with the
treatment failures of multiple alternative healers suggest that the old fashioned
elimination diet, as described by Theron Randolf, MD, over so many decades,
adapted to the special needs of FM patients, is a good place to start. It should
be the foundation of higher level, more invasive, or expensive treatments to
follow, in the event that they become necessary. At the very least, it can
be said that a proper elimination diet and management of inhalant exposure
will "pick the low hanging fruit" that constitute the successful
treatment of a majority of FM patients.
Please feel free to call us to discuss networking and sharing resources such
as our online symptom tracking, printed treatment protocol, and the manual
for consolidating and maintaining symptom remission.
Chuck Bates, PhD
Fibromyalgia Program at the Clinic at Panorama City
PO Box 4453
Tumwater, Washington 98501