Hi there! My name is Jillian Ondreyka; I’m the resident dietitian on the HS Connect team. I have HS myself and started specializing in Nutrition for HS in my virtual private practice Embrace Health Nutrition in 2019. Check out my bio for more information.
I recently did a webinar on Food Sensitivities and Hidradenitis Suppurativa. Here is a link to watch the webinar. The same information is presented in this article.
I want to start by acknowledging how controversial this topic is! There is a lot of debate on the science of food sensitivity testing and which one is best. Immunology is a complicated science, and at this time we do not have enough research to show definitively what is the best path (or test). This article will walk you through the basics of adverse food effects, elimination diets, and the food sensitivity tests available now and how they work.
How do you figure out if you have food sensitivities?
Your first question might be, “So how do I figure out if I have food sensitivities?” Well, sometimes the connection isn’t always clear, and you have to be a food detective! I always recommend that people start using some form of a food journal if they aren’t already doing this.
To help you journal, I worked with HS Connect to create the HS Flare, Lifestyle and Food Journal. There is a place to write down the date of your flare. Then, try to think back to everything that was happening around or right before you had the flare. You might be able to identify some things that could have triggered it. This journal is based on a literature review of HS articles about lifestyle and food. More on this below!
What are adverse food reactions?
There are 3 ways that a food can cause an adverse reaction:
Allergy
Intolerance
Sensitivity
See chart below for details of each.
Below is another visual to explain this concept and how these terms are related. For food sensitivities, there are two main pathways in which these reactions occur, type III and IV.
Type III reactions, also known as immune-complex reactions, occur when IgG, IgM, or IgA antibodies bind to a food antigen and trigger white blood cells to release mediators, which causes symptoms.
Type IV reactions, also known as cell-mediated reactions, occur when white blood cells (lymphocytes or granulocytes) are independently triggered to release mediators, without the involvement of antibodies.
Both of these types tell white blood cells to release mediators. This release of mediators can cause symptoms in all parts of your body. The time it takes from eating the food to having the symptom can vary. Sometimes, you might notice a symptom immediately. Other times, you might have a delayed start of the symptom. For food sensitivities, the symptoms can be delayed up to 4 days. So, if you are looking for a food sensitivity test, you want one that will measure ALL types of possible pathways.
How do food sensitivities cause inflammation?
Food sensitivities make a person feel sick because the immune system reacts to foods and causes the release of chemicals called mediators (such as histamine, prostaglandins, cytokines, etc.) from white blood cells. It’s the mediators that cause the inflammation, pain, and other symptoms associated with food sensitivities.
In fact, food sensitivity is a very complex reaction by our immune system. There are many different cells that have different profiles of mediators, many mechanisms that cause mediators to be released, and of course, many different mediators.
These are the summarized steps of how food sensitivities cause inflammation. First, the immune system identifies the food or substance as foreign. Then, the triggering mechanism triggers the immune cells to react (like calling in the troops). Chemicals are released from immune cells to destroy the invaders. This release of chemicals travel to the bloodstream and cause a wide range of symptoms.
Back to how do you figure out if you have food sensitivities?
You’ve probably heard of elimination diets, which help you identify food sensitivities by trial and error. Basically, you remove a food and see what happens! The careful process of eliminating and reintroducing foods and using a food-symptom journal will help you determine what, if any, foods trigger symptoms.
If foods do trigger symptoms, then removing these trigger foods will allow your body to recover. The timeframe of an elimination diet is about 4 to 6 weeks. I recommend starting with removing one type of food or you can remove the most common food triggers. Removing more foods is not always better! Avoiding too many foods can make it to strict to the test diet and it can be stressful. Starting small will make it easier to follow and more enjoyable. The top three “usual suspects” that cause adverse reactions are gluten, dairy, and sugar. Start with eliminating 1 food, and then you can continue to eliminate additional foods if your symptoms persist.
Common Food Triggers of Allergic and Inflammatory Reactions:
Dairy
Gluten (wheat, rye, barley)
White (Table) Sugar
Flour/products
Corn
Peanuts
Soy
Eggs
Shellfish
Caffeine
Vinegars and fermented foods
Yeast products
Alcohol
Nightshade vegetables. Nightshades include white potatoes – but not sweet potatoes – eggplant, tomatoes, goji berries, cape gooseberries, huckleberries, ashwagandha, peppers and spices made from peppers.
Beef/Pork/Fatty meats/ processed meats
What can I eat?
I like to focus on the foods you can enjoy during this time. This will depend on which food or food category you are eliminating. Here are some options that are common in elimination diets:
Meat: chicken, turkey, lamb, cold water fishes like salmon or sardines
Nuts (except peanuts), seeds, almond milk, nut butters
Vegetables: all except nightshade vegetables if you are avoiding those.
Soups: clear broths
Fats/oils: olive oil, walnut oil, coconut oil, sesame oil
Grains: brown rice, quinoa, buckwheat, millet
Legumes: lentils
Fruits: 1 cup/day of any fresh or frozen berries, plus your choice of 1 banana, 1 apple, 2 kiwis (limit fruit if you have diabetes/metabolic syndrome)
Spices: all spices, including garlic and onions, are excellent to include – many improve digestion and metabolism; avoid those that trigger reflux if this is a problem for you
Beverages: water, carbonated water, water with lemon, green tea, herb tea
Sea salt to taste
Other foods that you can think about adding to your eating plan are anti-inflammatory foods. See below for a list of the most common choices to soothe inflammation:
Omega-3 (anti-inflammatory) fatty acids
Fatty fish: salmon, mackerel, cod, tuna, sardines
Extra virgin olive oil
Nuts and seeds: almonds, walnuts, flaxseeds
Dark leafy greens: kale, broccoli, collards, cabbage, etc.
Red and blue foods contain anti-inflammatory phytonutrients called polyphenols
I like this infographic from Harvard that summarizes foods that fight inflammation like tomatoes, fruits, nuts, olive oil, leafy greens, and fatty fish and foods that can cause inflammation like fried foods, soda, refined carbs, lard, and processed meats.
You might also want to check out the 3-Day Anti-Inflammatory Meal Plan and anti-inflammatory recipes on HSConnect.org.
Challenge/Re-introduction
Now that you have avoided a certain food or food category for a bit, it’s time to start introducing foods in and watch for symptoms. I recommend testing 1 new food every day, or if you want to go slower, then add 1 new food every 3 days. Most adverse reactions from a food will occur within 48 hours, but can occur up to 96 hours after consumption. If you have symptoms when introducing a food, take it back out of your eating plan and try again in about two weeks. It is really important during this phase to keep a food journal of everything you are eating and any physical symptoms you are having. This will allow you to connect the dots and determine what foods trigger what symptoms in your body. Once you have determined your trigger foods, you can decide to keep the offending foods out of your eating plan or enjoy them in small amounts if you want to.
Tips for Success
Plan, plan, plan! As with many things in life, it’s super helpful to have a plan of how you are going to achieve your goal. With elimination diets, it’s helpful to think about your meals and snacks in advance. Having healthy foods on hand makes it easier to handle hunger when it strikes and to follow your eating plan.
Check the ingredient labels on your foods. If you don’t know what the ingredient is, look it up. Some foods and food additives have multiple names. Trigger foods can be hiding in a place you wouldn’t suspect!
Eat regular meals and snacks. Having a regular meal timing and being consistent in your eating will help you control your hunger and stick to the meals you have planned. Avoid being hungry for long periods of time and don’t skip meals.
Drink enough water: at least 6 to 8 8 oz glasses and more if you are exercising.
Rest up – sleep is vital for your health and reduces inflammation (bonus!).
Keep Your Eyes On The Prize (Good Health)!
A healing mindset is so important. Whole health includes your mental, emotional, and physical health. Although elimination diets are the gold standard for identifying food sensitivities, following an elimination diet can lead to feelings of deprivation and stress which can be harmful to your health. Try to have a positive mindset to help you heal during this period of trying something new.
Here are some tips to help you maintain a positive relationship with food:
Keep your goal in mind – you want to eliminate symptoms, not pleasure in eating! Re-frame elimination diets as a way to eliminate your symptoms. If someone asks, explain that you are following an eating plan to eliminate symptoms.
Make sure you eat enough; don’t let yourself stay hungry. Focus on adding in more protein, fat, & veggies to satisfy your hunger.
Remember that these eating plans are meant to be short-term, about 6 weeks. This will help you avoid nutrient deficiencies.
Don’t be afraid of the reintroduction phase! These phases are essential in helping you build your own healthy food plan. The goal is to identify the least restrictive eating plan that will make you feel well.
Most importantly- Remember to do something that feeds your soul every day! Take a nature walk, talk with friends or family, breathe deeply, listen to music, paint, read, write, or anything else that brings you joy.
Food Sensitivity Tests
There are several tests out there to measure food sensitivity. Keep in mind that these tests are not designed to diagnose food allergies as that is a different mechanism. There are also other food reactions that may not be captured; for example, if you eat too much fiber and have some bloating, the test would not be able to tell you that. This is one reason why it’s helpful to work with a Registered Dietitian Nutritionist when trying a new way of eating. Below are summaries of each food sensitivity test.
Enzyme-Linked Immunosorbent Assay Immunoglobulin G (ELISA IgG)
Immunoglobulins are antibodies in the blood.
Explanation: This test quantifies how much IgG you are producing to a specific food.
Pros
Accurately measures IgG levels
Cons
High levels of IgG can be either good (suppressing of an immune response) or bad (causing an immune response) and test doesn’t differentiate
Tests one mechanism- Type III
Does not test for chemicals
Antigen Leukocyte Cellular Antibody Test (ALCAT)
Explanation: Cell-based blood tests assess changes in your white blood cells when exposed to food antigens
Pros
Can detect both type III and type IV foods sensitivities
Large testing panel 357
Cons
It is a good, but older method that has been replaced by MRT (same inventor Dr. Pasula)
Mediator Release Test (MRT)
Mediators are what cause food sensitivity symptoms, so they are the MOST IMPORTANT thing to measure.
Explanation:
Cell-based blood tests assess changes in your white blood cells when exposed to food antigens.
All the immune based adverse reactions end up causing mediator release- this is what is measured.
Pros
Captures several mechanisms
Tests 170 foods and chemicals
Accounts for the widest range of inflammatory pathways
MRT measures the release of mediators, which is the event that happens right before an inflammatory reaction takes place.
Cons
The reactions are hard to track back to which mechanism caused what
Lymphocyte Response Assay (LRA) by ELISA-Act
Explanation: Lymphocytes are exposed to antigens and the cell response is studied.
Pros
504 antigens tested
Cons
Details are vague -No studies on methodology or efficacy (if it works)
Results are averaged which may lead to error
HS-Specific Research: Brewer’s Yeast Sensitivity
Saccharomyces cerevisiae includes brewer’s yeast, baker’s yeast, and nutritional yeast. This is an ingredient used in baking to help foods rise and in fermentation
In a 2013 study, 12 patients were tested with the IgG ELISA test, and all had a specific reaction to yeast. They started a yeast-controlled/ yeast-free diet and all had stabilization of symptoms of skin lesions that improved over 12 months. They experienced an immediate recurrence HS in 24-48 hours if they accidentally or on purpose ate yeast containing foods.
In this 2020 study, the researchers tested out a yeast-free diet. Of the 37 who followed a yeast-free diet, 70% had improved HS when they eliminated Brewer’s yeast. 87% of those had recurrence of HS with yeast in less than a week. ~4/37 people were tested for food intolerance (IgG). Yeast sensitivity was found in 20%, wheat sensitivity was found in 29%, and cow’s milk sensitivity was found in 23%. The authors suggested that a form of food intolerance might be the missing link to understand HS – which I think is fascinating! This is why I use a type of food sensitivity testing (MRT) with my clients that have HS, more on this below.
The authors also provide a summary of the diet restrictions and recommended diet below:
Foods not allowed:
All bakery products (eg, pizza, bread, cakes, etc.) vinegar, black tea, soy sauces, beer, wine, fermented cheese (eg, gorgonzola, bleu d’Auvergne, etc.), mushrooms
Foods allowed:
Vegetables and fresh fruit, cereals that do not contain yeast (eg, rice or corn cakes made with puffed cereals), white meats, eggs, vegetables, green tea, coffee
Putting it Together
Remember earlier when we talked about how food sensitivities cause inflammation? Let’s go back to that to see where the testing methods come into play. Under mechanisms, we have the antibody-based test. Some immunologists consider IgG to be the gold standard because it has been in more research studies. But remember, high IgG doesn’t necessarily mean it is causing symptoms. The rest of the tests are cell based. The ALCAT has been replaced by the MRT, and the LRA has limited studies to explain their methods. The MRT is measuring the release of chemicals that travel in the bloodstream and cause symptoms, which makes it the most useful test!
Based on the information I just shared with you all, my professional opinion is that the MRT is the best food sensitivity test because it is able to measure the mediators being released which is what causes the symptoms. Want to learn more about how I use the MRT? Read on!
Lifestyle, Eating, and Performance program using the Mediator Release Test (MRT)
LEAP stands for lifestyle, eating, and performance. This is a personalized anti-inflammatory eating protocol based on a food sensitivity test called “MRT” or Mediator Release Test.
As I mentioned, it’s been brought up that food intolerance could help us understand HS. The MRT is actually able to account for a much wider array of reactions than IgG testing. I also believe that the MRT is the most reliable and sensitive, or accurate, food sensitivity test which is why I use it.
This test tells you how strongly your immune cells react to foods and food chemicals. Most people see 50-80% improvement in 10 days. This stat is not HS specific, but based on clinical experience in fibromyalgia, IBS, and migraines (the first topics MRT was studied in).
Below is a picture of a sample MRT report, but everyone could have different food reactions so please don’t stop eating mushrooms because you see it on this sample report! What’s great about having this test is that you can see the foods that your body reacts to and which ones it doesn’t react to, so it’s very personalized. The test results will tell you which foods are “safe” to eat. These are the foods you will eat for about 4 weeks to give your immune system time to calm down. The goal is to reduce inflammation in your body. You can only eat MRT-tested, safe foods and ingredients for a period of time. If a food or ingredient isn’t listed in your plan, don’t eat it. After you start feeling better, you will add in one new food a day and watch for symptoms. This is why during the program, you will have to track your food and symptoms in a journal.
The package of nutrition counseling that accompanies the MRT test and follows the LEAP protocol is outlined below:
1st appointment (1.5 hours)
Discuss results
Build nutrition plan together
2nd appointment (30 minutes) Day 10-14
Discuss food-symptom journal and symptom survey
Add in more tested foods
3rd appointment (30 minutes) Day 30
Discuss food-symptom journal and symptom survey
Add in untested foods
4th appointment (30 minutes) 45-60 days
Discuss food-symptom journal and symptom survey
Decide if graduating or more follow-ups
Before getting started, I like to talk with people to make sure the program is a good fit and the time of year is good (no planned vacations or holidays).
People are most successful following LEAP if they can say “yes” to the following:
I can dedicate time to preparing and cooking meals at home made from scratch.
I will eat only the foods on my LEAP nutrition plan for the duration of the program, 6-8 weeks.
You might be wondering why this is, because on most diet programs it is okay to “cheat”. In this case, the “cheating” might be making you sick! Foods not on your LEAP nutrition plan might actually be causing inflammation in your body. To get the most health benefit and biggest bang for your buck, I recommend avoiding outside foods until later in the program. See picture below to help explain this concept visually.
I can dedicate time to track everything I eat and any symptoms I have in a journal every day for the duration of the program, 6-8 weeks.
I can dedicate time to plan out all of my meals/snacks to make sure I have options that are within my nutrition plan. I can use recipe ideas from Embrace Health Nutrition, the MRT/LEAP Pinterest page, and the LEAP MRT Community Group on Facebook.
The most important things to remember
If you remember just a few things from this article, I’d like you to focus on these 3.
Healing mindset- aim to have a positive mindset and use food as a powerful tool to heal your body
Keep a journal- I find this tool invaluable in helping you find your HS triggers! Remember to download this free HS Flare, Lifestyle, and Food Journal if you haven’t already.
Eat more anti-inflammatory foods (tomatoes, fruits, nuts, olive oil, leafy greens, and fatty fish) and limit inflammatory foods (fried foods, soda, refined carbs, lard, and processed meat).
Sources & further reading:
Silfvast‐Kaiser, A., Youssef, R., & Paek, S. Y. (2019). Diet in hidradenitis suppurativa: A review of published and lay literature. International Journal of Dermatology, 58(11), 1225-1230. doi:10.1111/ijd.14465; Aboud, C., Zamaria, N., & Cannistrà, C. (2020). Treatment of hidradenitis suppurativa: Surgery and yeast (Saccharomyces cerevisiae)–exclusion diet. Results after 6 years. Surgery, 167(6), 1012-1015. doi:10.1016/j.surg.2019.12.015
Cannistrà C, Finocchi V, Trivisonno A, Tambasco D. New perspectives in the treatment of hidradenitis suppurativa: surgery and brewer's yeast-exclusion diet. Surgery. 2013 Nov;154(5):1126-30. doi: 10.1016/j.surg.2013.04.018. Epub 2013 Jul 25. PMID: 23891479.
Susan Linke LEAP MRT Videos: https://www.youtube.com/channel/UCL5cUGPqLzSx-gAiYVAFCNQ/videos
Content in this article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking treatment because of something you have read on this website.
Written by Jillian Ondreyka, MPH, RDN, IFNCP, IBCLC, CLT
Edited by Brindley Kons-Brooks