HOW STRICT DO YOU HAVE TO BE ON AIP?: Is the Full Autoimmune Protocol Always Necessary?
When it comes to dealing with autoimmune conditions, in the Functional Medicine world we say that food is medicine and nutrition can heal. But does this really mean that in order to recover from any autoimmune issue everyone must adhere to the strictest elimination phase of the Autoimmune Paleo Protocol Diet - at least for some period of time?
I would suggest that the answer to this question is no.
This conclusion is based on both clinical and personal experience, but also on a deep understanding of the role, purpose and goals of an AIP regimen. In this article I will explain how the tool that is AIP may be incredibly useful, but also why it may not be entirely necessary. I will also detail how the act of following AIP can prove both distracting and detrimental to progress when tackling autoimmune conditions.
Nothing in the following article is laid out to refute the science of AIP or doubt the evident success that many individuals achieve using this approach.
The purpose for writing this is because I have seen the overly restrictive nature of AIP regimens create almost as many problems as it has solved - psychologically, emotionally and physically. If the full AIP restrictions are NOT always clinically indicated then it is my opinion that a more liberal approach will better serve those for whom the psychological burdens of attempting AIP leave lasting scars.
THE SCIENCE OF ELIMINATION DIETS AND AIP
I have explained the science of elimination diets fully in the AIP area of Paleo In The UK, but a brief overview is as follows:
Elimination diets are designed as a reset button which removes what are commonly-considered the most inflammatory or allergenic foods. This list of foods is based on research and science - a mixture of mechanistic and epidemiological data as well as some randomised, controlled trials conducted into specific nutrients or foodstuffs (and now, even into the full AIP dietary protocol). This isn’t a ‘medical’ diet, but the work of several key individuals and a collective of people who have used this nutritional approach to, typically, heal themselves and many others.
The AIP diet eliminates EVERY foodstuff that we know of that can negatively influence digestive health, homeostatic balance and the human immune system. The foods eliminated are either inflammatory themselves, tough to digest, create broad swings in hormones or blood sugar and/or they upregulate immune or inflammatory cascades.
The real magic of an AIP diet doesn’t exist in understanding what is left out - because this is not personalised and highly non-specific. Instead, from the beginnings of this large, catch-all net of eliminations, the precision medicine comes in as the strict elimination recalibrates each individual’s immune system and from there foods are reintroduced and we are able to gauge the individual’s personal level of reactivity.
The basic explanation of this (further expanded by Sarah Ballantyne in The Paleo Approach) is that when antibodies are made in a state of generalised inflammation (i.e. whilst suffering from autoimmune conditions), there is always a degree of immune control occuring in which the body is also producing compounds which are working to reduce inflammation all the time. In this milieu, understanding what a person is truly reactive to is almost impossible.
When immune/inflammatory stimuli are removed from the body for a period of time inflammation falls. Antibody levels drop and so does the creation of all of the compounds which were trying to keep inflammation in check.
In this context, when you reintroduce a food to which the immune system is genuinely reactive, the reactivity is more acute and noticeable (there is no background reactivity OR the presence of compounds which are working constantly to reduce inflammation).
This is why Elimination AND REINTRODUCTION are utilised in immune system dysregulation, such as in autoimmune conditions. They serve a two-fold process - they calm the waters of mass reactivity and immune hyperactivity AND they provide information as reintroductions are made which can provide a unique and bespoke template of dietary reactivity.
The discovery of what truly ‘aggravates’ someone’s immune system is fundamental in autoimmunity because whenever the immune system is being triggered (for example, by those foods) inflammation and generalised antibody production will rise. In those with autoimmunity, self-antibodies will continue to be made - and their autoimmune issue will continue.
This calming, learning process is not a permanent ‘truth’, however - and this is often confusing or misrepresented in the AIP literature. The human immune system transforms with the passage of time and in response to many things other than diet. Learning what doesn’t suit you today does not give you a template for life.
Additionally, and this is even more misrepresented in the AIP world - this is not a ‘fix’ for the immune system because what broke the immune system was all the foods that are eliminated. Autoimmune conditions are evidence of an immune system in disarray. This is rarely caused by food alone. The AIP Diet is, therefore, a treatment - much like a medication. And, as such, the necessary dose can vary according to the reality of the situation for each autoimmune patient.
THE RATIONALE BEHIND EXTREME ELIMINATION DIETS LIKE AIP
The reason AIP is not designed for the long term is because it is not sustainable over the long term.
AIP is extreme - and for good reason.
However, that reason has little to do with there being compelling data behind every food eliminated. Instead, it’s because we know that in some people, certain things can create issues and therefore ‘to be sure’ and ‘just in case’, we thoroughly clear everything out of someone’s diet that may, potentially and perhaps, cause them to have a reaction. And yes, all of these ‘maybe’ words are used intentionally - the AIP is all based on science, but it isn’t really scientifically personal - it’s just a best guess, a bit of mechanistic understanding and an ‘if in doubt, eliminate it’ approach.
This means it’s broad - and does not mean that every food eliminated is a problem for every person with an autoimmune condition. Yes, some of the foods eliminated might be triggering to a certain level - we just have no idea which ones and how severely they may be triggering. So we cut everything, calm the waters - and then reintroduce.
Instead of this basic explanation that AIP is a catch-all diet designed as an overzealous nutritional approach that serves as an extreme intervention to stop all potential immune offenders, AIP is often sold as a one-size-fits-all miracle cure that, when followed to the letter, can heal anyone of autoimmunity. It is also sold as highly scientifically validated and incredibly specific - with the threat that deviation from any part of the AIP diet will result in a worsening of health.
And yet, AIP is a tool designed to clear the confusion of a dysregulated immune system that has developed an autoimmune condition. With INCREDIBLY rare exception, food is not the cause of autoimmune conditions. (The exception is Coeliac Disease, and even then there are other factors involved.) And if food is NOT the CAUSE of autoimmunity… removing foods is only ever PART of a solution.
And if food is not the CAUSE of autoimmunity, meticulous adherence to punitive diet plans may not even be required in order to address the roots of someone’s autoimmune issues. Logic would suggest that if it wasn’t the foods that made you ill, removing them cannot be 100% necessary for healing.
THE EFFECT OF EXTREME AIP
Extreme AIP can work wonders, when done right and with the correct headspace. And yes, headspace is important - because the foods should never be painted as the enemy and nor should the immune system.
Instead, it must be understood that in autoimmunity the body is in a state of overwhelm and hence super-sensitive, over-protective and slightly unsure about what to attack so it attacks the self. Autoimmunity is a ‘when in doubt, attack everything’ solution to a problem of a body being overly stressed. PART of that stress may lie within someone’s diet… but rarely, if ever, all of it.
Extreme AIP can therefore clear the triggers from the food landscape for an individual with autoimmunity. It is also an empowering exercise - you feel like you’re proactively addressing your physical wellbeing and that sense of empowerment has a ripple effect.
Done right, AIP should place nutrient density and overall nourishment high on the list of priorities - meaning that sleep, rest, appropriate exercise and socialisation are also attended to. Generally, this is all a focus on self-care, wellbeing and supporting our bodies. All of this will transform health because autoimmune conditions so often emerge in the context of stress. Reversing this stress to attend to self-care can reverse the autoimmunity.
Done in this way, AIP’s magic comes from more than just the elimination of specific triggering foods… it’s truly an holistic exercise in re-regulating the nervous system, the immune system and the psychology of each individual.
THE CONSEQUENCES OF AIP
The PROBLEM is that AIP is often taken onboard as a stressful ‘must-do’ which is mandatory if we expect to heal. The nutrition becomes a pressure, the list of eliminations a burden and if things don’t seem to be working the sense is that you have failed and must “AIP Harder” .
Clearly, all of this angst will negate the benefit of any dietary restriction. But the other consequence is that in order to understand the diet many people take to researching. And when looking into the dietary recommendations the word ‘anti-nutrients’ is used … A LOT.
In Paleo and AIP, eliminations are based on the concept of anti-nutrients - not empty calories or lacking nutrients, but proactively containing compounds which take nutrients away, work against us and cause damage and destruction.
We are told that proteins or molecules in foods are literally attacking us from the inside out. Images are painted of holes in gastrointestinal tracts (think lectins and ‘leaky gut’) and angry immune molecules waging war against anything that subsequently ‘leaks’ into our bloodstream from a perforated gastrointestinal tract.
We are also sold the fact that certain nutrients in food can be bound up so we can’t get at them (this is marginally, infinitesimally true and largely insignificant). Worse, we’re authoritatively informed that the binding molecules in certain plants can actually bind up other nutrients and leave us with nutrient deficiencies (which is actually utter and complete nonsense - scroll down to the graphic “Oxalate is a Salt, Not an Anti-Nutrient” at this link).
With the surfeit of information about foodstuffs, the molecules, salts, acids, polyphenols and flavonoids in our common, everyday fruits, vegetables, grains, nuts, seeds and eggs are portrayed as akin to poison.
This can be slightly forgiven, because certain plant compounds do stimulate a mini-stress response within the human body. From this understanding it is not a huge mental leap to conclude that foods as benign (and yummy) as tomatoes and goji berries are the work of the devil… But actually, in most individuals those mini-stress responses are termed hormetic stressors - i.e. the kind of responses which improve physiological resilience, not work against it.
When I run through nutrition with my clients I hear so many factoids about food that emerge from the literature in this field. However, to every ‘truism’ based on the negative impacts of foodstuffs, I can counter this with the benefits inherent in the very same foods.
Put simply: foods aren’t bad for you. And if you read the AIP propaganda you can easily fall into the paralysis of thinking that they are. When you eliminate them and feel better this can feel like proof of concept - but in truth, I don’t think we fully know all of the impacts of embarking upon an AIP regimen. As I said above, we’re changing more than just diet - we’re changing our headspace, our approach to stress, our awareness of how we’re treating our own bodies AS WELL AS our nutrient balance. It is not possible to isolate all of the moving parts here and understand what makes the difference.
If I were a betting person, I would lay money on the fact that it’s rarely the foods that make the biggest shift in the immune system of those with autoimmunity, The reason I say this is because I have seen people heal without even eliminating wheat, often considered the most ‘toxic’ of foods. I have also seen that hyper-focus on the diet, performing the eliminations meticulously, can also result in a complete lack of improvement.
If the diet was the be all and end all, doing it to perfection would always result in a ‘cure’. Instead, dietary perfection can often distract us from addressing the other issues which contribute towards autoimmunity - and it may sound far-fetched but it is nevertheless true that it is those who are perfectionists by nature who often trip into autoimmune conditions simply because they tend to be excessively hard on themselves in everyday life.
So if the diet isn’t always fully necessary, how do you know what’s relevant? What are the rules? Does food even matter at all?
THE MIDDLE GROUND - AND HOW MECHANISM ISN’T ALWAYS MEDICINE - AND HOW FOOD ISN’T THE ISSUE, EVEN WHEN IT’S PART OF THE SOLUTION
Finding a middle ground - or where you personally need to pitch your AIP attempt - is always going to be the tricky part. For many reasons this is why most people would recommend complete adherence to extreme AIP for at least 30 days.
Beyond this there are certain foods which are probably wise to completely eliminate and steer clear of pretty much forever, simply because they pile loads of stress onto the biochemistry of everyone, and those with a history of autoimmune or chronic illness just don't need that stress:
Rancid, overheated, damaged fats
Overly processed, fake foods
Artificial stuff - sweeteners, dyes, preservatives
Then there’s the stuff that should probably be avoided for a little while, particularly if autoimmunity has been going on for some time - based on the data that we have (empirical and research-based) which suggests that proteins and/or the modern varieties of the following are commonly reactive:
Gluten and probably corn and oats for a while (note: I did not say grains)
Dairy
Refined sugars
Nuts
Eggs
And then there’s the things which I feel are more in the area of being very individual and tolerance will more than likely depend on history, cultural background, digestive wellbeing (not all autoimmune conditions have gut dysbiosis as part of them), preference etc. etc. It is these foods which I feel may indeed form part of a well constructed, nutrient-dense diet - even for someone tackling autoimmune conditions:
Legumes - chief amongst the ‘I’m not sure these are terrible category’ - I wonder deeply whether legume sensitivity is a property of gut health, not immune function. Lectins have been made out to be the devil and yet so many healthy cultures, blue zones etc. have legumes (and, for that matter, whole grains) as part of their diet… I’m not so sure these (or lectins themselves) are the devils that they are made out to be
Nightshades - especially potatoes, but often aubergines, tomatoes etc… (though I do feel that the spices derived from other nightshades may be best avoided initially, due to both the concentration of the compounds, but also for the fact that chilli/paprika etc can be quite irritating to the gut lining). For some, nightshades are their downfall and really trigger inflammation. For others, nightshades are completely OK. Terry Wahl’s MS protocol does NOT eliminate nightshades for everyone. If you can have these in your diet, they are a real boon to digestion and overall wellbeing, not a trigger
Seeds… some seeds (think cumin, coriander, black cumin) are used medicinally in ancient cultures and eastern traditions… can they really all be immune triggers???
Rice… technically a grain, but realistically I really don’t think it deserves to be classed in the grain category - particularly when you factor in the fact that white rice has had its outer husk removed. So often carbs can be lacking in AIP - and carbohydrates are deeply relaxing to the human body. This means that if you can tolerate some grains then having them in your life help to turn OFF the panic/alarm bells of the body, not aggravate them
My rationale for the above is both common sense AND scientific. The ‘perhaps these aren’t too bad’ list contains foods which are included in some of the healthiest diets in the world - and the questions I have over lectins, nightshades and seeds reflect the lack of scientific evidence that these ‘anti-nutrients’ are really that aggravating at all.
Certainly, to some, they are - but to others they are practically superfoods. This would suggest to me that autoimmune treatments do not succeed or fail based on these nutrients - and that reactivity to these still denotes an underlying immune hyperactivity which may just as easily be approached with OTHER methods as it is addressed by removing foodstuffs from the diet.
The main reason for stating any of this at all is because I have seen almost as much damage created by the AIP approach as I have seen benefit. This is all to do with the psychology piece of how we interact with nutrition and wellbeing. From a society which didn’t believe food mattered in health we are slowly becoming nutritionally obsessed, believing that food is the ultimate and only regulator of wellness and ‘eating right’ is the only way to be OK.
And it is my belief that it just isn’t.
The human body is brilliant. Even mine. I have survived eating next to nothing, eating only refined carbs and sugars, eating meals every 3 hours, eating nothing for days. I have survived diets of total enteral nutrition and diets filled with dairy and gluten. I have also survived on less than I truly need for a long time. I have been through a lot when it comes to food… and through all of it my body has miraculously kept going doing the best it could with what I was giving it.
In a world where fasting (i.e. basically starvation), ketosis (i.e. extreme macronutrient restriction) and veganism (i.e. extreme nutrient manipulation and avoidance of a huge part of the food chain) are the latest fads, I believe that the onus is on us, the nutrition professionals shepherding the message behind any ‘diet’, to paint them in an accurate light - and the truth is that avoiding foods, whatever food that is, may not be the ultimate route to healing.
When you are dealing with an illness of a stressed and highly challenged body, more control, regulations and restrictions is precisely the wrong energy for healing…
If you need to hear that the science we have behind the foods eliminated on the AIP diet is inconclusive - then I hope you can hear that message in this article. I am someone who KNOWS the healing magic of eliminating the right foods to allow your body to heal - and yet I STILL state that this doesn't have to resemble any dietary template you can find on the internet. The trick is in finding YOUR dietary boundaries and what suits your biology. And you don't need to stick to someone else's template or else risk never getting better.
It is simply not true that consuming just one mouthful of the foods eliminated on an AIP diet will set your body back. In fact, believing this to be the case is the perfect way to prime your immune system to react - even when there was no reason to. The best way to heal from any autoimmune condition is to focus on self-care and treating your body the way it needs to be treated. For you, and for many individuals, this may NOT include extreme restriction or over-control... and no, you may NEVER need to go on an AIP regimen and still find your own route to healing...
If this article has confused you, sparked intrigue, made you feel afraid of whether you're over-restricting, controlling or whether you can eat a broader diet, do reach out to me and I'd be delighted to help. If you, or someone you know, is trying to control even tighter and harder in an attempt to heal then please seek support and guidance. And please don't believe anyone who tells you that there is only one way to do this - there are MANY ways to heal from autoimmune and chronic illness. The key is to find your way. And it may leave far more on the table than you've been led to believe.