Elimination diet: the end

The long awaited end to our elimination and challenge diet has arrived.  After three and a half months of monitoring everything my son and I ate, we can now go to a party without bringing our own food!  During this period we challenged salicylates (twice), amines, and glutamates, and my son also challenged bread preservative.  My son finished his second salicylate challenge a few days ago, and he'll be off the diet tomorrow (I finished a little over a week ago).  I'm disappointed to report that the only thing I've learned about my son's skin condition from all of this is that my son does not have a severe reaction to any of these things.

That's not to say he didn't react, just that it wasn't obviously caused by the challenge food.  The value of this knowledge is not to be dismissed, however his reaction to each challenge was difficult to interpret.  As I've mentioned in previous posts on the topic, his skin never completely cleared.  Even with periodic use of cortisone ointment, the eczema would inevitably appear after a few days on the elimination diet without drugs.  The big question was whether the severity had reduced.  At this point I've concluded that he is not unusually sensitive to any of the chemicals we challenged.

Though I'm eager to expand our vegetable intake, we won't go back to our previous eating patterns immediately.  I expect to introduce certain foods with caution.  For instance, our diet previously relied on high intake of tomato, which is high in salicylates, amines, and natural glutamates, and often associated with eczema.  One thing I will introduce immediately is flaxseed oil, as I feel that the elimination diet is distressingly low in essential fatty acids (since everything we ate had to comply with the diet, even supplementation was restricted).  He will have flaxseed oil instead of butter on his toast (I've discovered that when drizzled over toast with a little salt it is a totally suitable substitute for butter), and whenever he would have had butter or oil that is not cooked.  We will also introduce a number of vegetables and fruits that are only moderately high in salicylates, and cut way back on meat, chicken, and sugar intake, which always felt too high to me.

Lessons learned
We didn't need to spend so long to learn what we did from this experience.  We had to repeat challenges to correct early mistakes in execution. Even now, there are things I should do to make up for mistakes made in the beginning, but I've lost the enthusiasm to continue.  If I ever have to go through this again, I will do a number of things differently.

What do I consider essential to success while minimizing the pain and duration of the diet?   This is written in regards to my experience with eczema, but most of it applies regardless of the condition you are trying to treat.

Do the allergy tests first.  You will have more success with the diet if you avoid all foods and other irritants to which you have a positive allergy test.  If your doctor suggests it, you can challenge those foods and then reintroduce them into your diet if you do not have a reaction.

Get your hands on one or both of the cookbooks for this diet (Friendly Food and The Failsafe Cookbook).  I use them nearly every day.  The recipes are fantastic, even if you don't end up doing the diet, and Friendly Food, in particular, is a very good source for people who need to avoid eggs, gluten or wheat, nuts, dairy, or soy.

Stock your larder, experiment with recipes, and make some of the staples (like pear jam) before you start in earnest.  Make a few things you can put in the freezer.  It will be a lot easier to stick to the diet if you already know how to make a few meals that comply with it and know where to buy the ingredients.  You will not have the option to make a last minute dash to get take away on this diet.

Rearrange your kitchen so that the food you will not be allowed to eat is separate from the food you are allowed to eat.  For instance, put all forbidden food into a cabinet separate from everything else so you do not get confused or tempted.  If you keep snacks in your bag or your car, make sure they comply with the diet as well (we used plain rice cakes and rye cruskits for this).  In the refrigerator, designate the least visible shelf for the forbidden food (things that won't go bad during the three or so months you're on the diet, like ketchup and jam, and anything your family members insist on having).

As much as possible get your entire family to follow the diet when eating in the presence of the people on the elimination diet. You may find it handy if you allow the consumption of forbidden foods out of sight of family members who are following the diet, especially right after challenges, when you will probably have left-overs that you can no longer consume but you don't want to waste (for instance, we had cherries and carrots left after our salicylate challenge, so I sent them to work in my husband's lunch).  They can also be used to slowly rid the freezer of forbidden foods.

If you have the flexibility, do the diet in the winter.  Many of the allowed vegetables are not available or of poor quality in the summer and you won't be taunted by all the beautiful summer fruits.

If you have the flexibility, don't start before the holidays or lots of birthdays.  Sticking to the diet is far more pleasant when you don't have to eat out frequently.

Take detailed notes.  Keep a description of symptoms in your food diary rather than trying to rate their severity as a number.  This will be much less subjective.  Even better: get a person who does not know whether you are doing a challenge or in the elimination phase to evaluate the symptoms; it is very easy to let your own wishes interfere with your judgment.

Prior to starting the diet, find out how the skin responds after two weeks without cortisone.  While eating your normal diet, treat the skin until it is clear, then take notes on the symptoms for two weeks.

Use the cortisone the way the doctor specifies (i.e. don't try to go
without).  Use it as directed for the first week of the diet, when withdrawal symptoms are most likely to occur and to prepare the skin for a two week elimination challenge (see next point).

After starting the elimination diet, but prior to starting challenges, find out how the skin responds to two weeks on the diet without cortisone.  A week after you start the elimination diet, do a two week elimination challenge where you do not use cortisone to determine if the elimination diet has resulted in an improvement.  If not, consider what else you might need to eliminate or consider stopping the diet altogether.

Label everything you put in the freezer with 1) the contents, 2) whether or not it follows the diet, and 3) the date it was made.  If you are avoiding amines, this will help you avoid eating meat that is too old.  It will also ensure you don't accidentally eat the zucchini risotto you made for the salicylate challenge during your amine challenge.

Conclusion
Since eczema runs in families (I have it, my dad has it, my son has it), there's a pretty good chance any other kids I have will get eczema, and I may find myself going through this again.  If it happens when they are only a month old, I will do the elimination diet immediately to see if it has any positive effect.  I will also continue to look for other solutions to the problem.  If nothing else, I've learned how to do this better the next time.