LEAP Elimination & Rotation Diet Protocol Training

1LEAP Elimination & Rotation Diet Protocol Training Jan Patenaude, R.D.Director of Medical NutritionSignet Diagnostic Corp.

Hi and Welcome to the LEAP Diet Training. Over the next hour or so, well cover the basics of the LEAP Diet Protocol. Ill be doing an overview of the LEAP Immunocalm Diet Report and then cover some specific issues that often arise.

First, just a brief introduction. My name is Jan Patenaude, Ive been a Registered Dietitian since 1982 and have worked in a wide variety of settings over the years; from hospital clinical and food service director to consulting to long term care, home health care, drug alcohol rehab, prisons and jails, TV, radio and Im a published author. I was in private practice and taught weight control and wellness classes for many years. Currently, Im Director of Medical Nutrition for Signet Diagnostic Corporation, telecommuting from my home high in the Colorado Rockies, doing patient counseling, writing, training, some marketing, sales and public speaking.

Of all the work Ive done, working with LEAP clients has been among the most rewarding.Its exciting to repeatedly see lives turned around; people that were crippled by IBS and chronic diarrhea, or migraines, or chronic pain and now have control back in their lives, and minimal or significantly reduced symptoms. Ive been challenged professionally to learn a new area of dietetics and I must say, even after 4 years of working with MRT/LEAP, I still learn something new every day.

However, I could not achieve the dramatic and rapid results with my patients without the MRT test results to guide my diet recommendations. As the person who is guiding a LEAP patient with their LEAP Immunocalm Diet, its important to recognize that although the LEAP results are key, using good clinical judgments and guidance also helps assure the best results for each client. 2Getting StartedFor this LEAP dietary training you need:

A LEAP Immunocalm Diet Report (i.e. Sample patient LEAP report)Pen for note-taking

So, lets get started and lets make sure you have the materials well cover. You will want to have a real or sample LEAP Immunocalm Diet Report.

I want to be sure you have read over the report, cover to cover, at least once before you proceed with this PowerPoint training any further. If you havent had a chance to read though your report, turn off this presentation, and continue after you have read through the report.

Also, feel free to take notes in your sample LEAP Report. When counseling clients, you will refer to your notes often. Lets go to slide 3.

3Getting StartedLets do a tour of the LEAP Immunocalm Diet Program Booklet.The LEAP ImmunoCalm Diet is an elimination diet based on the individuals MRT results. Each patient receives his or her own LEAP ImmunoCalm Diet Plan

Lets do a quick review of each section of the LEAP Report. There is really a lot of information here, and when working with patients, the more familiar you are with the sections, the more youll share those sections with patients, as well well review for this training. First there is the Cover sheet and Table of Contents. Pages 1 and 2 are an introduction and overview. After that, youll see 2 pages of the bar graph of the individual patients test results. Note that green is considered non-reactive, yellow is moderately reactive and the longest, red bar is highly reactive.

On pages 3 & 4 are more instructions, then youll note the individuals LEAP ImmunoCalm Diet Program or Phase 1 to 5 Elimination diet. Following that page is Phase 6, which is a 3 day Rotation Diet.

In Section 2, we have Frequently Asked Questions; Common and Hidden Sources of Test Substances; Chemicals and Additives; Alternatives for commonly eaten items; a Food Families Guide (the botany people really get into this section!); and Additional resources. In time, there will be additional information and revisions as well.

Each patient receives his or her own LEAP Immunocalm Diet based on their MRT test results.4Understanding MRT Test ResultsMRT is a food sensitivity test, not a food allergy test.I know Im allergic to strawberries. Why didnt it show up in my test results? Regardless of MRT results, patient should avoid known problem foods. The goal of LEAP is to help establish a healthy eating plan for all patients, while eliminating all reactive foods from their diet.

Understanding MRT Test results.You should already understand from the Immunology Training that MRT is not an IgE allergy test, it is a test for Type 3 and Type 4 Hypersensitivity reactions identifying those foods that trigger mediator release due to loss of oral tolerance.

Patients will often say, I know Im allergic to strawberries (or nuts). Why didnt they show up reactive. Its very important that patients understand that MRT testing will not pick up an IgE allergic food anymore than a hemoglobin blood test will tell us if we have iron overload disease.

However, regardless of MRT results, if a patient suspects any food as being a problem food for them, then it should be removed from Phases 1-3, at least, and only added back after the patient is doing well, if at all. All known IgE allergens should be avoided indefinitely.

Finally, the goal of LEAP is to help establish a healthy eating plan, while eliminating all reactive foods.5Turn to your LEAP ImmunoCalm Diet Program Test Results page

Now, lets turn to the LEAP ImmunoCalm Diet Program Test Results page. This is the bar graph showing levels of reactivity. Note the various foods categories. Vegetables, grains, chemicals, fruit, meat/poultry, seafood, flavor enhancers, and on page 2: beans/nuts/legumes; dairy and misc. You might also note that avocado and olives are listed with fruits; lemon is in flavor enhancers, etc. The more you work with the diet, the more comfortable you will become with this report.

This is the cornerstone of the LEAP DM program. But, just knowing or avoiding reactive foods is usually not adequate for the best results.

6LEAP ImmunoCalm Diet Phase 1Limited to 20 - 25 items or lessConsume freely.Whole foods, cooked from scratch, ideallyOrganic recommendedBetter to eat 4-5 smaller mealsDrink plenty of water (64 oz/day)Salt may be added in moderation.Withdrawal: May feel worse before you feel betterShould see significant improvement in 7-10 days.

So, we do a phased Elimination diet, based on test results. During Phase 1 the diet is limited to no more than 20-25 of the lowest reactive items. By limiting the number of foods, in case a person doesnt do well in 7 10 days, the diet is limited enough that we can figure out IF theres still a trigger food present.

We recommend that Phase 1 foods can be consumed freely. Use whole foods, organic and cooked from scratch ideally. (Ideally, but not always possible.) Its better to eat 4-5 smaller meals a day to prevent hypoglycemia. We encourage people to drink plenty of water, generally 8 cups a day, minimum. More if they are comfortable with that.

Hypoglycemia and dehydration are both common migraine triggers, so this information is especially important for a migraine patient.

Eliminating all reactive foods often causes the body to shed retained water weight, so dehydration could be a concern thus, the need for a good water intake, and maybe instructing clients on the symptoms of dehydration, such as thirst, dry lips, constipation, dizziness upon standing quickly, fatigue and low back pain.Salt may be added in moderation. Baking soda and distilled white vinegar may also be added to phase 1 if desired. (We recommend Spectrum Brand White vinegar, as its corn, not petroleum based.)Finally, as a warning, many people feel worse before they feel better. Maybe flu-like symptoms, or fatigue, or even worsening migraines. Often, if clients wean them selves off reactive foods for a week or two before doing a full Phase 1 diet, they wont see as many withdrawal symptoms. Other clients never feel worse, but just are amazed in 3 days how good they feel.

We should see significant improvements in 7-10 days. If not, action needs to be taken, but, well discuss that more fully, later.7Why cant I just avoid my yellow and red foods?Answer: Assume reactive to ALL untested foods until proven otherwise.

Okay, so I hear this phrase often. Why cant I just avoid my yellow and red foods?

My answer:If a food is NOT in phase 1, its not allowed. We test 150 foods and chemicals. A typical American Diet might contain 500 different foods and chemicals. If a person only eliminates reactive foods, they still could be eating highly reactive foods or chemicals, and not know it, and never get well.

We make the assumption that all non-tested foods are reactive, until proven otherwise. They can, and should be added back into the diet after phase 5, or at least wait until the persons symptoms have resolved significantly, and theyre feeling great, then try adding untested foods back into the diet.

8THERES NOTHING TO EAT! ILL STARVE!

Answer: My phase 1 diet was a feast/banquet compared to what millions of people in 3rd world countries have to eat. Just that realization made it easier.

The next comment Ive heard frequently: Theres nothing to Eat. Ill Starve! Usually with GREAT emphasis and/or whining! ;-) Americans are pretty spoiled and nobody has starved to death on phase 1 yet. Helping patients to adjust their paradigms about deprivation and lack will help them adhere to phase 1. I often remind people that If I was a native American, in winter, 150 years ago, Id think my phase 1 diet was a feast! or You know what Theres a billion people in third world countries that would think your phase one was a banquet-even if thats all they had for the next month! You only have to survive this for a week or two. When we adjust our attitude, it doesnt look so hard after all, and since its temporary, your diet will begin to improve significantly in a couple weeks.It is not an easy diet. But, weve learned through many, many patients, that most are happy they made the sacrifice. The potential benefits far outweigh the costs.On the other hand, it IS a major lifestyle change, especially for somebody that never cooks. For that reason, if the patient tested has somebody else in his or her house that does the cooking, I ask that person to sit in on the consult as well.

For others, Ive suggested that they take a week or 2, or 4 to get ready for the diet, finishing foods they already have on hand, reviewing the materials and getting ready mentally.

9If you think it will make the difference between adherence and non-adherence, consider making small diet changes, trading some preferred foods from phase 2 (or even phase 3 if necessary) to phase one.

Now, If you think it will make the difference between adherence and non-adherence, consider making some diet changes, trading phase 1 foods for phase 2, or maybe even phase 3 foods. For example, a person that detests fish and/or beans; lives in a very small town with limited shopping choices; or is really struggling financially, has sole, red snapper and duck in phase 1. In that case, I might put the fish and duck in phase 2, and move a phase 2 protein like beef or chicken to phase 1.

I refer to the bar graph to help with these change decisions, and also have the patient assist. If their phase one fruits are honeydew, pumpkin, watermelon and papaya, and its the dead of winter in the north, these may be next to impossible to find. Id then ask the patient which of the phase 1 AND 2 fruits would they prefer. Also, sometimes, 3 or more fruits might be equally reactive, but because cranberry comes alphabetically before peach or watermelon, cranberry may show up in phase 1, with peach and watermelon in phase 2. If my patient would prefer peach or watermelon (or whatever) over what is in the earlier phase, I switch it out.I also check their reactivity levels. If a phase 2 food is significantly higher, I wont suggest the change. But, if a phase 2 food really is close in reactivity to a phase 1 food, Ill consider changing the diet. (Sometimes computers dont work as well as humans! The computer doesnt care about the foods you dont like or your lifestyle, but maybe we can get good results with a few changes.)Also, if somebody hasnt checked off any foods in their Food Avoidance Form but during their instruction, tells you, I think all dairy foods bother me. In this case, Id move any phase 1 diary foods to phase 2 or 3 (depending on other choices).

10Food Chemical ReactionsDose relatedMay not be enough in a food antigen to trigger, but may trigger if enough of food is eaten that contains a food chemical Modify diet to move foods from early phases to later phases that contain highly reactive chemicals (this tends to be a clinical judgment on the part of the counselor)And, if no improvement in 7-10 days, suspect other hidden chemicals

Okay, now, lets look at the Food Chemicals (and some misc. items) that are tested, but do not show up on the LEAP Immunocalm diet page. Most food chemical reactions are dose related, thus, just because a chemical is reactive, doesnt mean it cannot be consumed in any amount.But, also, it is possible to have a positive (Highly Reactive/Red) reaction to a chemical, but a negative reaction (low green) to a food that contains that chemical.The reason for this: There may not be enough of the chemical IN the antigen for a particular food to trigger a reaction. However, if a person eats enough of that food, it may trigger a reaction.For that reason, the LEAP diet that the person actually follows should reflect that, by manually moving a low reactive food in Phase 3 or 4, instead of phase 1. Solanine as an example. If somebody is solanine reactive, Id move all solanine foods (potato, tomato, eggplant, green pepper, cayenne, paprika) to phases 4 or 5, and when/if a person is feeling great, let them add the low reactive, but solanine containing food back, and monitor their response.Or: Tyramine reactive RD as an example that tested red to tyramine but low green to eggplant, but was a vegetarian and eating a whole eggplant a day . . . never got migraine free till we got her off eggplant.

If no improvement after 7-10 days, suspect that maybe there are still reactive chemicals lurking in the diet and/or medications and review meds and the Food/Symptom Diary carefully.

11Food Chemicals TestedAcetaminophen, Ibuprophen (Meds only) Aspartame/Nutrasweet (may contain maltodextrin-corn)Benzoic Acid (If highly reactive, may want to limit raspberries, cinnamon)Caffeine Wean off gradually. Common migraine/IBS/insomnia triggerCandida Albicans (Naturally present, not found in food)

Im going to review the chemicals tested alphabetically, for the most part. Turn to Food Chemicals page in your LEAP ReportACETAMINOPHEN and IBUPROPHEN: These are not found in foods, but if reactive, meds should be reviewed, and ideally a different analgesic can be recommended (refer to pharmacist or physician if a prescription med). ASPARTAME and/or NutraSweet. We all should know where these may lurk. But, just a note: Equal also contains maltodextrin, which is typically corn based. Somebody that is highly reactive to corn, but non-reactive to aspartame might still not tolerate Equal, because of the corn in it. (Ive seen this only one time in 4 years, but for that one patient, the maltodextrin was a serious diarrhea trigger even in trace amounts.)BENZOIC ACID Personally, Ive only seen it to be a problem when used as a preservative, but potentially, if highly reactive, the foods containing natural benzoates might be a problem. For that reason, if somebody was a pretty high red to benzoates, Id likely keep cinnamon and raspberries out of the diet till phases 4 or 5.CAFFEINE: Can be a common migraine, IBS and insomnia trigger. Caffiene can also trigger vasoactive responses separate from the mediator release that MRT testing is detecting, thus, I generally encourage all patients to eliminate caffeine if they have IBS, migraine or insomnia problems, if they are willing. If a patient is caffeine reactive, I usually suggest taking 7-10 days to wean off of caffeine prior to starting their full elimination diet. Caffeine may be in pain relievers as well, and most decaf coffee and tea still contains traces of caffiene. For most people, the levels may not be a problem. For extremely sensitive people, even decaf poses a problem.CANDIDA ALBICANS: This is a bit of a difficult one to assess clinically. If a person is highly reactive to Candida Albicans on MRT testing, that does not mean they currently have candida overgrowth, just that they are especially sensitive to it if absorbed in the gut. Ive come to look at this item, if reactive, in context of the whole person. Ill look at other yeast foods, like mushrooms, blue cheese and yeast for possible reactions. Ill review the patients symptoms and history. Does the patient have a known history of candida that has been treated? Do they commonly have yeast infections? Are they an IBS patient? Do they note worsening symptoms after sugar/sweets or high carb consumption. Occasionally, if a patient is highly reactive to candida, they found that anti-fungal treatments and limiting sweets, sugars and other mold/yeast sources was helpful. More often, Ive instructed the patient to ignore this until they complete phases 1 & 2 of the LEAP diet, but to limit sugar, honey and yeast and limit fruits to 3-4 servings a day, without fruit juices. If after completing phase 2, they feel wonderful, then we know candida isnt a major concern at this time. If they are still having significant symptoms, then I may investigate further, or refer back to their physician for further work-ups and or treatment. 12Food Colorings (Not a big concern diet-wise as most foods are in their natural state during early phases. May want to review mouthwash, toothpaste and medications, however.)Fructose (Mostly dose related issue)Lecithin (Corn, eggs, soy-often dose related)MSGPhenylethylamine and Tyramine (Common migraine triggers)

FOOD COLORINGS: Mostly you want to review medications, toothpaste and mouthwash. Even a trace of food coloring in meds has caused patients to NOT get well, until we changed their meds. Compounding pharmacies can be used to obtain coloring free meds. Or, if a patient is taking a 50 mg dose with a reactive color, is it possible to take 2 25mg doses without that color? This takes a bit of investigation. I encourage my patients to have their pharmacist review their meds for colors, but frankly, many refuse to do so for patients. Other options are checking medication inserts, labels, the PDR or online. One helpful website is www.rxlist.com. FRUCTOSE: If reactive, mostly I just be sure to eliminate soda, syrups, especially HFCS and candy. Some people may need to further limit higher fructose fruits and veggies, if after 2 weeks they are still having these symptoms. There is a fructose breath test (Hydrogen Breath Testing) that identifies if a person has an absorption issue with fructose which is a separate issue. If a person is fructose reactive on MRT test, it means that if absorbed, fructose will trigger mediator release for this person, and the resultant effects of the mediators. LECITHIN: The lecithin tested on MRT testing is soy lecithin. If somebody is highly reactive to lecithin, I will usually eliminate soy, egg yolks and corn oil from phases 1-3, and then reintroduce them when the patient is doing well. As this is dose related, most patients will tolerate smaller amounts, but not large amounts. One common source of lecithin in our diets is chocolate its not naturally present in cocoa, but is used as an emulsifier in prepared chocolate.MSG: Ive mostly noted that if somebody is MSG reactive, as long as they avoid added, processed sources of MSG, they do fine. In some cases, further restriction of all glutamate sources may be necessary, if the client that is MSG reactive isnt improving significantly by phase 2. Especially high glutamate foods like fermented foods, aged cheese, bouillon or tomato sauces. AMINES: PHENYLETHYLAMINE and TYRAMINE: These are both common migraine triggers, along with other amines such as histamine, which may be naturally present in foods, especially old/aged foods. Note in your LEAP report that they are naturally occurring compounds and reactions are usually dose related. Food sources of phenylethylamine are chocolate, red wine and aged cheeses. Major food sources of tyramine (and this list will vary slightly depending on the source of the info) are beer, wine, aged cheeses, liver, smoked or pickled protein foods, packaged soups, yeast based vitamin supplements, meat extracts, sausages, soy sauce and miso, eggplant, spinach, avocados, tomatoes, bananas, prunes and cocoa. Generally, as foods age, the amine levels increase. Thus, a migraineur that was tyramine reactive might tolerate a green banana, but not a ripe banana. To be on the safe side remove all these foods from the early phases of the diet, lets get the client migraine free and/or with significantly reduced symptoms, then try some of the lower tyramine foods in moderation and monitor responses. If somebody is reactive to phenylethylamine and/or tyramine, I often (but not always) find these clients also have a heightened sense of smell. If they do, I will often share the article by Joan Breakey, Whats Smell got to do with it. (Flavour article in the Files section of LEAP_RDs@yahoogroups.com along with further amine links.)13Polysorbate 80 (Sorbitol) Nitrates and Nitrites (natural and added- may want to test water.)Saccharin-the pink stuff (mouthwash, toothpaste)Salicylic Acid (Aspirin, personal care products and Food-dose related)Sodium Metabisulfite -Sodium Sulfite (Assume reactive to all sulfites)Solanine (Nightshade family) www.noarthritis.com

POLYSORBATE 80: Also Sorbitan monoleate, polysorbate 60, 40 and 20, sorbitol and sorbitan derivatives. Food sources are mostly processed dessert, cakes, cookies and baked goods, etc. Also ice cream, non-dairy creamers and of all things, Nexium, which so many of our patients take for GERD. Polysorbate generally only becomes a problem in later phases of the elimination diet when more processed foods are added back into the diet.NITRATES and NITRITES: These compounds are found naturally in some vegetables and well water or may be added in food processing, especially in cured and smoked meats. Nitrates are generally found in vegetables, well water and as a curative in processed meats. Nitrites are generally used in cured meats. SACCHARIN: Besides the obvious sources, mouthwash, toothpaste or meds might contain saccharin. Saccharine reactive clients could consider using baking soda for the first couple phases, get feeling good, then add it back and see how they do.SALICYLIC ACID: Also known as Amyl, phenyl, menthyl, glyceryl, dipropylene glycol esters or salts of salicylic acid. Aspirin is the most obvious source of salicylic acid with approximately 300 mg/tablet, but some people may be sensitive to as little as 15 mg of salicylate. We also find salicylates in personal care products such as lotions and food. Often salicylate reactive people will already know that aspirin bothers them. Absorption of large amounts of salicylate can cause vomiting, abdominal pain, increased respiration, acidosis, headaches, asthma, muscle aches, mental disturbances and skin rashes. Some patients do fine with natural salicylates, but react to processed and artificial salicylates. Other need to limit food sources of salicylates as well. Youll note in your LEAP booklet that food sources include many fruits and some nuts as well as many processed foods. Also, some very sensitive individuals will need to eliminate salicylates in sunscreens, lotions and toothpastes as well.If a patient is highly reactive, often Ill just eliminate meds containing salicylates, and limit fruit juices and nuts to reasonable quantities. If no significant improvement in 7-10 days, then patients may need to limit salicylate containing foods even further. A good website on salicylates is http://users.bigpond.net.au/allergydietitian/fi/sal.html.

SODIUM METABISULFITE and SODIUM SULFITE: If somebody is reactive to one, I assume reactivity to all sulfites, until proven otherwise. These are chemicals used in food processing as a preservative and sanitizing agent. It prevents bacterial growth and the browning of exposed foods. It also prevents the growth of undesirable microorganisms during fermentation and food processing. Reactions can include headaches, gas and/or diarrhea, nausea, skin rash, swelling, and wheezing. Often sulfite sensitive patients will note that their flatulence has odor of burnt matches (sulfur). The main food sources are processed potato products such as instant mashed potatoes, frozen French fries or hamburger helper type products. Also, fresh grapes, dried fruit and wine. For more information, read the sulfites article available on the LEAP_RDs@yahoogroups.com website or http://www.itmonline.org/arts/sulfa.htm.SOLANINE: Solanine is a chemical found naturally in the Nightshade family of foods, which include potatoes, tomatoes, peppers (all types of peppers except the spice, white or black pepper), eggplant and cape gooseberry. Tobacco is also a nightshade, so if solanine reactive, its another good reason for smokers to stop. Research indicates that people with arthritis may need to eliminate solanine foods for 2 to 6 months or more to see improvement. Others may find that small amounts of solanine are safe, but large amounts trigger symptoms. Do check out the website www.noarthritis.com for additional information. Also, as with many LEAP foods, somebody may show up highly reactive to solanine, yet low reactive to potatoes or other vegetables that contain the chemical solanine. If solanine reactive, I recommend removing all solanine containing foods from the diet until symptoms have improved or maybe up to 6 months.14Other ConcernsYeast (Brewers and Bakers)Lactose May cause symptoms even if diary is non-reactiveSugar (Cane vs. Beet)Coconut (May be very healing to the gut. Soaps-sodium laurel sulfate.)Mint (Mouthwash, toothpaste, gum)Cottage Cheese (dry curd)Yogurt (plain, not flavored)Meds-PDR, inserts, www.rxlist.com

Some other concerns:YEAST: Signet tests a combination of Brewers and Bakers yeast, found in yeast breads or beer. If a patient is highly reactive, screen for other symptoms of yeast overload. Especially if ALSO candida reactive, or history of problems with yeast and/or molds. Yeast is not currently added to the printed LEAP diet, so add it according to how reactive a person is to yeast. If a patient is yeast sensitive, they may do well with yeast free, sourdough breads available from health food stores under the brand names Pacific Bakery or French Meadow.LACTOSE: We should all be familiar with lactose intolerance, and realize that if somebody is low reactive to diary products, they still might be lactose intolerant. Thus, if Im working with an IBS patient, Ill usually move all dairy products to phases 2, 3 or 4 and then add back to the diet when the IBS is resolved.SUGAR: Just a note that sugar may be made from sugar cane or sugar beets. If the label just says sugar its impossible to know the source unless you contact the company. Some people that are cane sugar reactive may tolerate beet sugar or vice versa, although a sugar beet is in the same family as red beets, they are not the same thing.COCONUT: Some research suggests natural coconut may be healing to the gut. However, if somebody is highly coconut reactive, they may also need to be cautious with the ingredients sodium laurel and/or sodium laureth sulfate. Coconut is used in many soaps, dish soap, shampoos and such. I had one patient with a horrible skin rash that cleared when she stopped using soaps containing coconut based ingredients. Cocoamide and cocoate are other terms for coconut in products. MINT: If mint reactive, suggest patients avoid mint in mouthwash, toothpaste and gum for at least the first few phases of the diet, then add back cautiously. If they cannot find mint free toothpaste, I suggest using plain baking sodafor the first few phases.COTTAGE CHEESE: Signet tests only the dry curd type of cottage cheese, not the whey portion, so inform patients to start with dry curd, or rinse the cottage cheese in a strainer. Also, some brands of cottage cheese contain many untested ingredients or possibly reactive ingredients like sorbic acid; so have clients look for a very plain, organic brand of cottage cheese.YOGURT: Much the same as with cottage cheese, remind patients that we test only plain yogurt, not vanilla or fruit flavored yogurts. Also, many brands contain additional untested ingredients, so again, look for a very plain, even organic yogurt.MEDS: Keep in mind that medications may contain reactive ingredients. Have patients review their meds, or do so for them for reactive chemicals and/or carriers such as corn or potato starch. Use a PDR, medication inserts or the website www.rxlist.com.

15SO I STILL DONT KNOW WHAT TO EAT!Food Idea List (Review with patient)Hopefully, you can be creative with combinationsOrange juice concentrate, ginger and some leek with duck, chicken, fishOven roasted vegetables, brushed with oil and seasoningUse your slow-cookerRoast some meat, cook some grains, steam some veggies, add oil/nutsPureed or mashed fruit and/or juice for sauces

Some patients will state, So, I still dont know what to eat!

As the diet counselor, its our job to help the client come up with ideas, based on their allowed foods. First, be sure to have a copy of the Food Idea List and share this with patients. Many patients when they see rice wont think of rice vinegar, or rice cakes or brown rice syrup. Or, a patient that can have corn wont realize that Fritos corn chips are pure corn and help provide variety, even if not particularly healthy.

Get creative with combinations. Think about using juice concentrates to flavor roast meats. Teach patients how to oven roast their vegetables brushed with their allowed oils and seasonings or just salt. Suggest combinations that can be cooked in a slow-cooker. Suggest roasting meats, cooking some whole grains in a homemade beef or chicken broth, steam some veggies, toss allowed veggies, fruits and nuts for a salad, using a plain vinegar and oil mixture with allowed seasonings for a dressing. Consider using pureed fruits or juices for sauces. Consider plain baby food for a puree sauce. Review the Eating to Live article, or on the website for more ideas.16Menu, Shopping & Cooking Ideas Local Large Health food stores (Trader Joes, Whole Foods, Wild Oats, naturalgrocers.com, etc)Farmers marketsReferences in LEAP Booklet: Cookbook, Catalog listings, websitesTwo more: How to Cook Everything: The Basics by Bittman and Food Allergy Survival Guide by Melina, Stephaniak and AronsonLEAP Website www.nowleap.com (LEAP Patient Section) and www.nutritionresults.com

Encourage clients to peruse their local health food stores for ideas. I usually warn them to plan an extra hour or two or more for reading labels and looking for new products they probably didnt know existed. Consider farmers markets for lower cost and often a source of organic produce.

Refer to the references section of the LEAP report and I always encourage patients to get a copy of Jonathan Brostoffs book, Food Allergies and Food Intolerances. Used book stores or consignment stores are great sources of low cost allergy cookbooks.

Two good books that are not yet listed in the reference section are noted here. How to Cook Everything or How to Cook Everything; the Basics are great books for people who arent very experienced cooks. They also have a lot of nearly perfect, simple LEAP recipes, suggesting alternative ingredients and options for many basic recipes. The second book, Food Allergy Survival Guide is a vegetarian allergy book with more great recipe ideas.

Finally, encourage patients to visit the patient section of Signets website, www.nowleap.com and Michal Hogans website, www.nutritionresults.com. Michal has been a LEAP RD since 2004 and has combined a lot of ideas, resources and suggestions for LEAP patients.17Building a MenuReview patients Phase 1 FoodsGet creative. Can you come up with protein, starch, veggie and fruit dessert for a meal?Are there breakfast items available? If not, is client willing to eat non-breakfast foods for breakfast? Leftovers from last nights dinner?If not, some rearrangement may be in order.Lets look at your clients leap results-brainstorm ideas.Picky Clients Share Learning to eat new foods.

Building a Menu: Its important to provide clients with menu and meal ideas. For some additional ideas, review the article Eating to Live from the LEAP_RDs website, and share with patients as well! Talk to clients about being creative. We get stuck in ruts. In Japan, salty miso soup is considered a breakfast staple. Other countries routinely eat vegetables for breakfast, or fruit and nuts. Sometimes, our clients might be willing to eat leftovers for breakfast.

Ask you client if they are able to come up with enough ideas to make their diet livable, if not, get creative for them. If phase one foods are just too limited to build a decent diet, then, as mentioned before, consider substituting some low reactive foods from phase 2.

Take a look at the phase 1 and 2 foods with your client and do some brainstorming. Share recipe ideas if needed. And, I often look at the food avoidance form foods as well. Its frequent that a patient will check off a food on their food avoidance form like soybeans, because they dont think they ever eat them. So, soybeans wont be listed in the Elimination diet OR the Rotation diet. However, maybe a person that checked off soybeans is perfectly willing to use soy sauce, soy oil, or to add silken tofu to a blenderized fruit shake. If this is the case, then write these items back in to their diet as appropriate.18Consult 1: Approx 45-60 min See LEAP Affiliate Physician GuideEliminate all vitamins/minerals/herbs and OTC meds if possible, add back when stabilized.Summarize what youre about to coveredObtain patient verbalization that they are willing to follow phase 1 and keep food/symptom records.Set a start date with patient. Schedule F/U appt 7-10 days after patient plans to start diet.

How do consults usually proceed? Consult 1 generally takes 45-60 minutes, but can be as short as 20 minutes or as long as 2 hours, depending on the patient and the diet complexity. Point out to the patient that this is not a weight loss diet, but a diet to allow their gut to rest. We take you off all foods that are likely triggering symptoms, as well as those that werent tested. We have to assume foods not tested are reactive, until we can add them in in later phases. Generally recommend that the patient avoid all vitamins, minerals, herbs and over-the-counter medications when starting phase 1, and add them back in later, as needed.

After going over phase 1 of the diet with a patient, specifically ask them if this appears do-able for them, if not, ask what else needs to be changed. Frankly, some patients will only be willing to avoid reactive foods, and thankfully, some patients do very well with avoidance only. Generally, the sicker the patient, the more willing they will be to adhere fully to phase 1. I ask all my clients to keep a food/symptom diary and briefly cover how to fill it out. Let them know that if the diet works perfectly for them, and they feel wonderful in 7-10 days, then you may not need to review their food diary, BUT, if they dont do well, then youll definitely want to review their records.Set an actual start date with the patient. For some it will be the very next day, for others, it might be 2-3 weeks out because of work, travel, holiday or vacation plans. Schedule appointment 2 for 7-10 days after your client plans to start their diet. I usually prefer about 9 days, as 7 days is a bit early for some people to feel significantly better, but I dont want the patient that isnt doing well to go longer than 9 or 10 days before talking to me. Some patients are ready to start the diet the day after they receive their instructions. Others need a few days to plan, shop and/or even to finish-up the food they currently have in their refrigerator/cupboards. Others may have a vacation or trip planned, and want to start only after they return. Regardless, I usually recommend at a minimum that they begin to avoid yellow and red foods as much as possible.

Sometimes, if a patient has severe migraines, Ill recommend a period of just weaning off reactive foods for a week or two, and then get full-fledged into phase 1. This might reduce the risk of rebound headaches.

I also warn patients that they may feel worse before you feel better. So, if 3-5 days into the diet, theyre not so concerned if they actually feel worse for a few days.

Finally, I ask clients to complete another symptom survey shortly before our next appointment, but to fill it out for how theyre feeling now. . .Not how they felt for the past month as noted on the form.19Consult 2: 8-10 days after starting diet Symptom surveyIf No Significant Improvement in 7-10 days, review Food/Symptom records for:AdherencePattern of symptoms with 1-2 items?Dose related issuesIgE allergiesChemical issuesLectin issues

Consult 2 is very important. I always start by asking the client how the diet is going for them. Then, I review their new symptom survey and compare it with their original symptom survey. If the client is not seeing a significant improvement, then I review the Food/Symptom Diary with them, looking at adherence to the diet first. If a patient isnt being 100% adherent, they may not see good results, as some reactive foods trigger symptoms up to 3 days later. Follow the diet 95% but eat a reactive food twice in one week, and it may make enough of a difference that the patient doesnt get well. If they are not adhering, we discuss reasons, possible restart phase 1 again, or make minor changes that will lead to better adherence.

If a person is being adherent, but not seeing good results, we want to address dose related issues, reactive chemicals that might be present, possible IgE allergies, or even lectin which can trigger symptoms if the client is eating a lot of whole grains, beans or other lectin containing foods.

Also, if a person is not seeing significant improvements, we may need to review meds for trace amounts of reactive foods, colorings or chemicals. For example, I had one patient who after the first week was still having significant GI pain. She was potato reactive, and by calling the company that made her medication, learned that the starch in her med was actually potato starch. Switching to a different medication made all the difference for her. Even a trace amount of reactive dye in a persons medication has proven to be enough to make the difference between improvement and continued symptoms.20Consult 2: ContinuedFiber issuesLactose Intolerance (Should have been anticipated in Consult 1)Patient often knows/suspects what food is still a problemEliminate suspect foods, and continue with phase 1 for a few more days, until symptoms subside.If nothing else, may suspect medsContinue to build menu with more meal ideas

Other issues to consider are:FIBER I had one client that was feeling much better by day 7, but complained that Even though I no longer have IBS pain and cramping, it seems Im spending a lot of time on the pot. Upon review of his food diary, we learned he was eating nearly 50 grams of fiber a day with a new cereal he loved. We cut back on the fiber, and he did wonderfully.

IF an IBS client is still having gas or bloating, Ill suspect dairy as a trigger, and this is one reason I often keep dairy products out of phase 1, regardless of how low reactive they are. I do often allow clarified butter in phase 1 if a person is otherwise not dairy reactive. Some patients note increased gas, but often attribute it to eating more fruits and vegetables, especially if cruciferous or high in fiber.

If a person is still having significant symptoms by Day 7-10, I will ask the patient if there is anything they suspect is still causing problems. Often patients have a pretty good idea what food or foods are still causing symptoms. If a patient suspects any foods as still causing problems, we pull them out for 3-5 days, and see if symptoms improve. If so, I usually suggest avoiding that food for a couple weeks, and retest later. Just a comment here, it seems like Ive seen nuts to be a problem fairly frequently, if if they were low reactive. So, if we cant figure out what foods are still triggering symptoms, Ill usually take nuts out, and schedule a brief follow-up phone call to see how they are doing in 3-5 days.

If nothing else can be pinpointed, I suspect medications as causing a problem and will evaluate their meds more closely.

Most patients are doing great by consult 2, so I just recommend adding one new food per day from the phases, provide a few more meal or menu suggestions, and schedule for consult 3.21Consult 3: Rotation Diet4-5 weeks after patient begins diet. (Start Phase 6/rotation diet)Helps prevent new sensitivities from emerging.Have patient do another Symptom Survey, compare to earlier surveys45 min 1 hour.

Consult 3 is generally 4-5 weeks after clients start their LEAP diet to get started on a rotation diet.

At the beginning of consult 3, Ill again review a Symptom Survey with the client. Unless a patient was doing fantastic by consult 2, generally, you should see point lower at consult 3 than at consult 2. If not, discuss adherence issues, diet, lifestyle and whats going on with the client. Play diet detective, or possibly, the patient just needs to get back on phases 1, 2 & 3 for a week or two again, before starting a rotation diet.

Be sure to read over the Rotation Diet Ideas article, and share it with clients so they can read over it before consult 3. Explain that although the rotation diet is difficult, its designed to help prevent new sensitivities from emerging. I often feel its especially important for those LEAP clients that were highly reactive to many foods they ate frequently.

Consult 3 generally takes about 45 minutes to an hour.22Teaching Tips for Rotation Diet Arranged according to Food FamiliesIf you move a food to another day, move the entire familyIf you eat a food in its own family, and only eat it every 10 days, it doesnt really matter what day it falls in.Caution: Foods that are very similar in a food family should be consumed more cautiously, and need to be rotated (ex. Dairy or Gluten grains)

Look at your Food Families Guide and your Rotation Diet pages. Ill mostly use it as an example for this slide.

A rotation diet is a bit overwhelming at first, so I encourage clients to follow as closely as they can. Youll note that the rotation diet is arranged according to Food Family. All gluten grains are in one day. All cows milk dairy is in one day. All gourd family foods are in one day, etc. Ill point this out to clients, according to their personal rotation diet.

I often rearrange foods in a rotation diet to make it a bit easier to follow. For example, if the computer put lettuce and spinach in the same day, Id generally move one or the other to another day, thus allowing for two salad days instead of one. However, if you move spinach to another day, be sure to move all the foods from that food family to the new day, such as beets and quinoa.Another example, if a person didnt like pork or fish, and wanted to move chicken to phase 3, they could do that, but egg should probably be moved as well. But, since coffee and cocoa are in their own individual families, they could really be switched to another day without compromising the diet.Some major points. If you eat a food in its own family, and only eat it every 10 days, it doesnt really matter what day it falls in. For example: Maybe a patient goes out to a restaurant and they have duck. Duck is in a family by itself. (Go to index, find duck, review food family.) So, if the patient hasnt had duck for 2 weeks, it doesnt really matter if it happens to be Day 1, Day 2, or Day 3. . . go ahead and eat the duck.But foods that are very similar in a food family should be consumed more cautiously, and need to be rotated (example: Dairy or Gluten grains)Commentary: If a person eats yogurt every Day 2, and never eats cheese, then has a chance to eat cheese on Day 3, we dont recommend it. Obviously, there are exceptions, and if at friends, or eating out, we may not rotate completely. The main goal is to be eating a wide variety, and rotating as much as possible.

23Teaching Tips for Rotation Diet Try to find a milk, an oil, a sweetener and a vinegar/sour for each day. Cows milk, goats milk, soy milk, rice milk, almond milk, etc.Sweeteners: Honey, cane sugar, apple juice concentrate, saccharine, aspartame, brown rice syrup, corn syrup. Try stevia and maple syrup.Vinegar and/or sour (for dressings, vinaigrettes, flavoring): Distilled vinegar, apple cider, rice, and raspberry vinegars; red wine or balsamic vinegar (amine & sulfite alert); lemon juice or yogurt, buttermilk.

Some more teaching tips. Ill try to point out and/or arrange for patients to have a milk, a sweetener and a vinegar/or sour for each day of the rotation diet.

For example, see if you can arrange for cows milk one day, goats milk another, and consider soy, rice and/or nut milks on other days.

See sample patient: honey is in Day 1, cane sugar in Day 2, and since this sample patient wasnt reactive to aspartame or saccharine, use those, or try adding stevia on Day 3. Ill also try to find ingredients to make a vinaigrette or other salad dressing (if patients like salads/vinaigrettes) with each days vinegar, oil and seasonings or additional ingredients.

24Teaching Tips for Rotation DietKeep a Kitchen/Personal Rotation CalendarConsider starting a new rotation day before the Dinner (main) meal instead of at breakfast.Label items with a black marker: 1, 2 or 3Continue to add one new food a day.When all test foods have been added, start adding untested foods-Use Food Family Guide.If reactive to 2 or more foods in a food family, add other foods in that family with caution.

More tips: I suggest that each client keep a personal calendar. Write across it 1,2,3,1,2,3 to mark which day of rotation theyre on.

Also, many people prefer to start a new day before dinner. They then have enough leftovers from dinner for the next days lunch. And, choose breakfast and snack items from that day as well. Start a new rotation day before dinner the next day.

Suggest that the patient take a black Sharpy/permanent marker, and label their oil bottles according to which rotation day they are in. When preparing food, they can see at a glance which days oil to use. Now, continue to add new foods, one new food per day. After adding all the safe/green foods, then start adding untested foods, but do so intelligently.For example, a patient wants to try canola oil, arugula, Chinese cabbage or Brussels sprouts. Check out the index. Note they are not in the index. Scan the food families guide for them. Note they are in the Mustard (Cruciferae) family. Then, note if they were reactive to other foods in that family (mustard, cabbage, broccoli, cauliflower). If reactive to 2 or more, then add these new foods with caution. If not reactive to any other cruciferous foods, then they will likely be safe.

25Teaching Tips for Rotation Diet -moreIf a food is in a family by itself, and not commonly consumed, add it, monitor response. If safe add it into the rotation diet food list.In time, the rotation diet should contain MANY more foods.Consider homemade TV dinners. Prepare a full meal, place in divided freezer container or Ziploc freezer plate with cover. Label with masking tape and permanent marker. Freeze and have available when that day rolls around again.

Finally, if a food is in a family by itself, and not commonly consumed, have the patient add it and monitor how they feel. If they feel fine, consider that food safe or non-reactive and add it to the rotation diet.

For example: Say, by phase 6, you have a patient that wants to eat okra again. Go to your Food Families Index and look for Okra. Note its in the mallow family, so look alphabetically for mallow. Look at the foods listed there, and see that there are no MRT test foods in that family. If the patient is stable, have them eat okra. Continue to keep food records. Eat it a few more times, and if patient remains symptom free, then add okra to the Rotation diet, adding to which ever day the patient thinks it would fit in best. In time, the rotation diet should contain many more foods.

Another suggestion is to consider making homemade TV dinners. Prepare extra food of meals that freeze well and place in divided freezer containers or Ziploc freezer plates with a cover. Label with masking tape and a permanent marker. Freeze and have it available 3, 6, 9, 12 days later.

26Food/Symptom DiaryEssential tool for sleuthing out problemsRecommend them to ALL patients.They are a hassle, but a tool to getting well.Think of it as playing diet detective.Forces patient to pay attention to diet and symptoms.

The Food/Symptom diary is essential for sleuthing out problem foods. Signet provides a paper and a computer version of food diaries to use upon request, but use whichever form works best for you/your clients. I ask all patients to keep a diary, and explain that they are a hassle, but it really helps us be a diet detective in figuring out whats going on. A food/symptom diary also forces patients to pay attention to their diet and their symptoms.

I often tell a story of one of my patients. A year and a half into her LEAP diet, she was still having occasional bouts of severe abdominal pain, even when adhering to her LEAP diet. So, she called me one day to say that shed spent nearly 2 hours poring over 1 years worth of her food/symptom diaries. She said she finally noted a pattern of abdominal pain 72 hours after eating carrots and pears. She eliminated carrots and pears from her diet, and has done significantly better since. 27FOLLOW-UPOne month and two months after starting rotation diet.Repeat Symptom Surveys (SF-36 forms?)Monitor for adherenceReview Food/Symptom Diary if desiredwww.LEAPSelfHelp@yahoogroups.com

I generally follow-up after the initial consultations one and two months after starting the rotation diet. I ask to do a symptom survey to be sure that clients continue to do well. Sometimes, Ill find people completely fell off the wagon and are feeling bad enough that they get motivated to restart their diet. I also have them complete a SF-36 form for one of these follow-up meetings. (If working with LEAP patients in your private practice, you may choose not to do an SF36.) After a patient has done well, either consult 2, 3 or now, consider inviting them to the LEAPSelfhelp@yahoogroups.com listserv. It is a source of further ideas and recipes.28MOST DIFFICULT PATIENTS 65 year old, refuses to cook, only eats in local restaurant (Probably not a great LEAP candidate.)Client whos never cooked a meal in 45 years of life, eats all meals out.Assess willingness to make major lifestyle changes before testing. Patient unwilling to do full elimination or rotation diet, but still is thrilled with his results doing just an avoidance diet.

Just for a review, Ill share with you some of my most difficult clients. One was a 65 year old male that refused to cook. He eats all meals out in a local restaurant. Now, frankly, he probably wasnt a great LEAP candidate, but since hed been tested, I offered what I could. So, I went online, found his local restaurant menu, and provided suggestions hed never considered and hes done well even though he is only avoiding his most reactive foods.

Another client had never cooked a meal in her life. However she was willing to learn, and actually said she enjoyed cooking a month or so into her diet.

We do need to assess willingness to learn. Maybe somebodys health is so poor, they realize drastic measures are needed. Or, are they willing to hire a professional or a friend to do meal prep? Will a family member or friend help? If so, I include them in the consultations, if the patient is comfortable with that.

My approach for LEAP diet counseling will vary from client to client also. Recommendations for a economically stressed, single, working mother with 3 children that hates to cook will be quite different from that of a person that has plenty of free time, loves to cook and has unlimited financial resources. The first may only be willing and able to just eliminate reactive foods or eat from phases 1-3 combined for the first week. The other may be much more likely to follow the standard LEAP protocol exactly as recommended.

If unable or unwilling to do a full Phase 1-5 elimination diet, can they at least just choose only non-reactive test foods for 2 weeks. Ive even had clients that were only willing to avoid their reactive foods, but luckily, for some clients, thats enough to reduce symptoms.

I had one gentleman that was thrilled with his results all he did was avoid reactive foods. But he learned that it was one or two major foods that were triggering his migraines. One was rice, and he was the owner of 7 Japanese restaurants!

So, every client needs to be assessed individually, and worked with according to what they are able to do. 29

The best part of LEAP: Healthier, happier patients

And, for our last slide. The benefit of the LEAP DM program is: you get to significantly impact a persons health for the better and in ways that are often not possible without individualized MRT test results.

As one Gastroenterologist commented to me, One of the great things about LEAP I get a lot more hugs and kisses from my patients! But, then . . . I never see them again!

May you eventually lose your migraine, fibromyalgia and IBS patients! But, until then, if there is any way we can support you, answer questions, and assist, let us know.