1. SUCCESS WITH FOOD ALLERGY AND INTOLERANCE
Janice Joneja Ph.D., RD
J.M.Joneja, Ph.D. 2013

2. Food Allergy & Food Intolerance DEFINITIONS:
A generic term
describing an abnormal
physiological response
to an ingested food or
food additive which is
not immunogenic
Food Allergy
An immunologic
reaction resulting
from the ingestion
of a food or
food additive
J.M.Joneja, Ph.D. 2013

3. Symptoms of Food Allergy
Controversy among practitioners because there are no definitive tests for food allergy
Symptoms appear in diverse organ systems:
Skin and mucous membranes
Digestive tract
Respiratory tract
Systemic (anaphylaxis)
Symptoms in nervous system are considered more subjective and sometimes may be dismissed as fictitious or psychosomatic
J.M.Joneja, Ph.D. 2013

4. Examples of Allergic Conditions and Symptoms
Skin and Mucous Membranes
Atopic dermatitis (eczema)
Urticaria (hives)
Angioedema (swelling of tissues, especially mouth and face)
Pruritus (itching)
Contact dermatitis (rash in contact with allergen)
Oral symptoms (irritation and swelling of tissues around and inside the mouth)
Oral allergy syndrome

5. Examples of Allergic Conditions and Symptoms
Digestive Tract
Diarrhea
Constipation
Nausea and Vomiting
Abdominal bloating and distension
Abdominal pain
Indigestion (heartburn)
Belching

6. Examples of Allergic Conditions and Symptoms
Respiratory Tract
Seasonal or perennial rhinitis (hayfever)
Rhinorrhea (runny nose)
Allergic conjunctivitis (itchy, watery, reddened eyes)
Serous otitis media (earache with effusion) [“gum ear”; “glue ear”]
Asthma
Laryngeal oedema (throat tightening due to swelling of tissues)

7. Examples of Allergic Conditions and Symptoms
Nervous System
Migraine
Other headaches
Spots before the eyes
Listlessness
Hyperactivity
Lack of concentration
Tension-fatigue syndrome
Irritability
Chilliness
Dizziness

8. Examples of Allergic Conditions and Symptoms
Other
Urinary frequency
Bed-wetting
Hoarseness
Muscle aches
Low-grade fever
Excessive sweating
Pallor
Dark circles around the eyes

9. Anaphylaxis
Severe reaction of rapid onset, involving most organ systems, which results in circulatory collapse and drop in blood pressure
In the most extreme cases the reaction progresses to anaphylactic shock with cardiovascular collapse
This can be fatal

10. Anaphylaxis Usual progress of reaction
Burning, itching and irritation of mouth and oral tissues and throat
Nausea, vomiting, abdominal pain, diarrhea
Feeling of malaise, anxiety, generalized itching, faintness, body feels warm
Nasal irritation and sneezing, irritated eyes
Hives, swelling of facial tissues, reddening
Chest tightness, bronchospasm, hoarseness
Pulse is rapid, weak, irregular, difficult to detect
Loss of consciousness
Death may result from suffocation, cardiac arrhythmia, or shock

11. Foods and Anaphylaxis Almost any food can cause anaphylactic reaction
Some foods more common than others:
Peanut
Tree nuts
Shellfish
Fish
Egg
In children under three years
Cow’s milk
Wheat
Chicken

12. Exercise-induced Anaphylaxis
Usually occurs within two hours of eating the allergenic food
Onset during physical activity
Foods most frequently reported to have induced exercise-induced anaphylaxis:
Wheat (omega-5-gliadin) and other grains
Celery and other vegetables
Shellfish (shrimp; oysters)
Chicken
Squid
Peaches and other fruits
Nuts especially hazelnut
Peanuts and soy beans
May be associated with aspirin ingestion

13. Emergency Treatment for Anaphylactic Reaction
Injectable adrenalin (epinephrine)
Fast-acting antihistamine (e.g. Benadryl)
Usually in form of TwinJect® or Epipen®
Transport to hospital immediately
Second phase of reaction is sometimes fatal, especially in an asthmatic
Patient may appear to be recovering, but 2-4 hours later symptoms increase in severity and reaction progresses rapidly

14. Immunologically Mediated Reactions
IgE-mediated:
Immediate onset (anaphylaxis)
Oral allergy syndrome (OAS)
Latex-Food syndrome
Non-IgE-mediated
Eosinophilic gastrointestinal diseases
Food protein-sensitive enteropathies
Gluten-sensitive enteropathy (celiac disease)

15. Role of the Dietitian Accurate identification of the foods responsible
Elimination and challenge to confirm or refute:
allergy tests
suspected allergens and intolerance triggers
Directives for avoidance of the culprit foods
Recognition of sources of the offenders
Understanding new labelling laws

16. The Dietitian’s Role
Provide guidelines and resources to ensure complete balanced nutrition from alternative foods
Macronutrients
Micronutrients
Directives for prevention of food allergy and induction of oral tolerance
New guidelines
Ensure freedom from allergens in food provision and preparation services

17. Tests for Adverse Reactions to Foods
Rationale and Limitations

18. Skin Tests: Value in Practice
Positive predictive accuracy of skin tests rarely exceeds 50%
Many practitioners rate them lower
Negative skin tests do not rule out the possibility of non-IgE-mediated reactions
Do not rule out non-immune-mediated food intolerances
J.M.Joneja, Ph.D. 2013

19. Value of Skin Tests in Practice
Tests for highly allergenic foods thought to have close to 100% negative predictive accuracy for diagnosis of IgE-mediated reactions
Such foods include:
Egg  Milk
 Fish  Wheat
 Tree nuts  Peanut
J.M.Joneja, Ph.D. 2013

20. Blood Tests
RAST: radioallergosorbent test (e.g. ImmunoCap-RAST; Phadebas-RAST)
FAST; Fluorescence allergosorbent test
ELISA: enzyme-linked immunosorbent assay
Designed to detect and measure levels of allergen-specific antibodies
Used for detection of levels of allergen-specific IgE
May measure total IgE - thought to be indicative of “atopic potential”
Some practitioners measure IgG
(especially IgG4) by ELISA

21. Value of Blood Tests in Practice
Blood tests have about the same sensitivity as skin tests for identification of IgE-mediated sensitisation to food allergens
There is often poor correlation between high level of anti-food IgE and symptoms when the food is eaten
Many people with clinical signs of food allergy show no elevation in IgE
Reasons for failure of blood tests to indicate foods responsible for symptoms are the same as those for skin tests

22. Value of Blood Tests in Practice
Anti-food antibodies (especially IgG) are frequently detectable in all humans, usually without any evidence of adverse effect
IgG production is likely to be the first stage of development of oral tolerance to a food
Studies suggest that IgG4 indicates protection or recovery from IgE-mediated food allergy

23. Tests for Intolerance of Food Additives
There are no reliable skin or blood tests to detect food additive intolerance
Skin prick tests for sulphites are sometimes positive
A negative skin test does not rule out sulphite sensitivity
History and oral challenge provocation of symptoms are the only methods for the diagnosis of additive sensitivity at present
Caution: Challenge may occasionally induce anaphylaxis in sulphite-sensitive asthmatics

24. Commercial Testing and Food Allergy Management Programs
LEAP (Lifestyle Eating and Performance); Signet Diagnostic Corporation
Claims to “successfully treat … IBS, migraines, fibromyalgia, autism, ADD/ADHD, IBD, urticaria, chronic fatigue syndrome, obesity, etc.”
Negative aspects:
Testing based on “mediator release”
Not a recognized accurate method for allergy testing
Positive aspects
Management includes elimination and challenge, food substitutions and meal planning

25. Commercial Testing and Food Allergy Management Programs
Gemoscan Corporation:
HEMOCODE™ (Gemoscan) Food Intolerance System, and MenuWise™ Food Intolerance Plan “personalized naturopathic nutritional programs that promote well-being.” 
Available in retail stores (Rexall and Loblaws)
Price is $450 for 250 foods
Tests identify IgG antibody to foods
Customers receive support from pharmacist/naturopath, including consultation on appropriate vitamins and supplements
Negative aspects
There is no provision for dietetic counselling and thus a high risk for nutritional deficiency when the “reactive foods” are eliminated without sufficient knowledge to provide nutrients from alternate sources

26. Unorthodox Tests
Many people turn to unorthodox tests when avoidance of foods positive by conventional test methods have been unsuccessful in managing their symptoms
Tests include:
Vega test (electro-dermal)
Biokinesiology (muscle strength)
Analysis of hair, urine, saliva
Radionics
ALCAT (lymphocyte cytotoxicity)
J.M.Joneja, Ph.D. 2013

27. Drawbacks of Unreliable Tests
Diagnostic inaccuracy
Therapeutic failure
False diagnosis of allergy
Creation of fictitious disease entities
Failure to recognize and treat genuine disease
Inappropriate and unbalanced diets
Risk of nutritional deficiencies and diet-related disease
J.M.Joneja, Ph.D. 2013

28. Non-IgE-Mediated Allergies
Eosinophilic Gastrointestinal Diseases Food Protein Induced Enteropathies

29. Eosinophilic Gastrointestinal Diseases (EGID)
Expanded definition of food allergy now encompasses any immunological response to food components that results in symptoms when the food is consumed
Example is group of conditions in the digestive tract in which infiltration of eosinophils is diagnostic
Collectively these diseases are becoming known as eosinophilic gastrointestinal diseases (EGID).

30. Characteristics of EGID
Inflammatory mediators are released from the eosinophils, and act on local tissues in the esophagus and gastrointestinal tract, causing inflammation
In eosinophilic digestive diseases there is no evidence of IgE, therefore tests for IgE-mediated allergy are usually negative
Unless there is a concomitant IgE-mediated reaction to food

31. Eosinophilic Esophagitis
Symptoms most frequently associated with EO and considered to be typical of the disease include:
Vomiting
Regurgitation of food
Difficulty in swallowing: foods are said to be sticking on the way down
Choking on food
Heartburn and chest pain
Water brash (regurgitation of a watery fluid not containing food material)
Poor eating
Failure to thrive (poor or no weight gain, or weight loss)

32. Eosinophilic Esophagitis
Although the symptoms resemble gastro-esophageal reflux disease (GERD), the reflux of EO dose not respond to the medications used to suppress the gastric acid and control regurgitation (antireflux therapy) in GERD
There is emerging data to suggest that use of acid-suppressing medications may predispose patients to the development of EoE

33. Diagnosis of EoE Three criteria must be met:
Clinical symptoms of esophageal dysfunction
Oesophageal biopsy with an eosinophil count of at least 15 eosinophils per high-power (x400 mag) microscopy field
Exclusion of other possible causes of the condition
Dellon ES 2013

34. Eosinophilic Esophagitis Foods most frequently implicated in Children
Egg
Cow’s milk
Soy
Wheat
Corn
Peanuts
Tree nuts
Shellfish
Fish
Beef
Rye
J.M.Joneja, Ph.D. 2013

35. Six-Food Elimination Diet and EoE Adult study 2013
Foods eliminated:
Cereals
Wheat
Rice
Corn
Milk and milk products
Eggs
Fish and seafood
Legumes including peanuts
Soy
Lucendo et al 2013

36. Six-Food Elimination Diet and EoE
Indicators of positive outcome:
Biopsy eosinophil count (< 15/hpf)
Negative gastro-oesophageal reflux
Reduced eosinophil count: 73.1% of subjects
Maintained remission for 3 years
Incidence of single triggering factors:
Cow’s milk 61.9%
Wheat 28.6%
Eggs 26.2%
Legumes 23.8%
No correlation with allergy tests

37. Eosinophilic Gastroenteritis: Diagnosis by biopsy: Abnormal number of eosinophils in the stomach and small intestine Foods most frequently implicated
Egg
Cow’s milk
Soy
Wheat
Peanuts
Tree nuts
Shellfish
Fish
J.M.Joneja, Ph.D. 2013 37

38. Eosinophilic Proctocolitis Diagnosis by biopsy: Abnormal number of Eosinophils confined to the colon Foods most frequently implicated
Cow’s milk
Soy proteins
Most frequently develops within the first 60 days of life
Is a non-IgE-mediated condition
J.M.Joneja, Ph.D. 2013

39. Food Protein Enteropathies
Increasing recognition of a group of non-IgE-mediated food-related gastrointestinal problems associated with delayed or chronic reactions
Conditions include:
Food protein induced enterocolitis syndrome (FPIES)
Food protein induced proctocolitis (FPIP)
These digestive disorders tend to:
Appear in the first months of life
Be generally self-limiting
Typically resolve at about two years of age

40. FPIES Symptoms Symptoms in infants typically include: Profuse vomiting
Diarrhoea, which can progress to dehydration and shock in severe cases
Increased intestinal permeability
Malabsorption
Dysmotility
Abdominal pain
Failure to thrive (typically weight gain less than 10 g/day)
In severe episodes the child may be hypothermic (<36 degrees C)

41. FPIES Characteristics
Triggered by foods, but not mediated by IgE
Condition typically develops in response to food proteins as a result of digestive tract and immunological immaturity
Cow’s milk and soy proteins, usually given in infant formulae, reported as most frequent causes
Milk and soy-associated FPIES usually starts within the first year of life; most frequently within the first six or seven months
When solids foods are introduced, other foods may cause the condition
Recent research claims that rice is the most common food causing FPIES

42. Foods Associated with FPIES
Removal of the culprit foods usually leads to immediate recovery from the symptoms
Foods that have been identified as triggers of FPIES in individual cases include:
Milk
Cereals (oats, barley and rice)
Legumes (peas, peanuts, soy, lentils)
Vegetables (sweet potato, squash)
Poultry (chicken, turkey)
Egg

43. Prevention of FPIES
Most reports of FPIES indicate that exclusive breast-feeding is protective in potential cases of FPIES
None of the infants who later developed FPIES after the introduction of solids had symptoms while being exclusively breast-fed
Authors of these studies suggest that babies with FPIES while being breast-fed were sensitized to the proteins through an infant formula given during a period of immunological susceptibility

44. Diagnosis and Management of FPIES
There are no diagnostic tests for FPIES at present
Indicators include clinical presentation :
development of acute symptoms immediately after consumption of the offending foods (often milk- or soy-based infant formula)
absence of positive tests for food allergy
Elimination and challenge with the suspect foods will usually confirm the syndrome

45. Diagnosis and Management of FPIES
Removal of the offending food leads to symptom resolution
In most cases delayed introduction of solid foods is advised because of the possibility that until the child’s immune system has matured, a similar reaction to proteins in other foods may elicit the same response

46. Food Protein Induced Proctitis/Proctocolitis
Blood in the stool is typical
Condition typically appears in the first few months of life, on average at the age of two months
The absence of other symptoms, such as vomiting, diarrhoea, and lack of weight gain (failure to thrive) usually rules out other causes such as food allergy, and food protein enteropathies
Usually the blood loss is very slight, and anaemia as a consequence of loss of blood is rare
Diagnosis is usually made after other conditions that could account for the blood, such as anal fissure and infection, have been ruled out

47. Food Triggers of FPIP Most common triggers of FPIP include:
Cow’s milk proteins
Soy proteins
Occasionally egg
Many babies develop the symptoms during breast-feeding in response to milk and soy in the mother’s diet

48. Causes and Management of FPIP
The cause of FPIP is unknown, but does not involve IgE, so all tests for allergy are usually negative
In most cases, avoidance of the offending food leads to a resolution of the problem
When the baby is breast-fed, elimination of milk and soy from the mother’s diet is usually enough to resolve the infant’s symptoms
Occasionally egg can cause the symptoms, in which case, mother must avoid all sources of egg in her diet as well

49. Progression of FPIP
In most cases, the disorder will resolve by the age of 1 or 2 years
After this age, the offending foods may be reintroduced gradually, with careful monitoring for the reappearance of blood in the baby’s stool

50. Elimination and Challenge
Protocols

51. Identification of Allergenic Foods
Removal of the suspect foods from the diet, followed by reintroduction is the only way to:
Identify the culprit food components
Confirm the accuracy of any allergy tests
Long-term adherence to a restricted diet should not be advocated without clear identification of the culprit food components
J.M.Joneja, Ph.D. 2013

52. Food Intolerance: Clinical Diagnosis
Elimination Diet: Avoid Suspect Food
Increase Restrictions
Symptoms Disappear
Symptoms Persist
Reintroduce Foods Sequentially or Double-blind
Symptoms Provoked
No Symptoms
Diagnosis Confirmed
Diagnosis Not Confirmed
J.M.Joneja, Ph.D. 2013

53. Elimination and Challenge
Stage 1: Exposure Diary
Record each day, for a minimum of 5-7 days:
All foods, beverages, medications, and supplements ingested
Composition of compound dishes and drinks, including additives in manufactured foods
Approximate quantities of each
The time of consumption
J.M.Joneja, Ph.D. 2013

54. Exposure Diary (continued)
All symptoms graded on severity:
 1 (mild);  2 (mild-moderate)
 3 (moderate)  4 (severe)
Time of onset
How long they last
Record status on waking in the morning.
Was sleep disturbed during the night, and if so, was it due to specific symptoms?
J.M.Joneja, Ph.D. 2013

55. Elimination Diet Based on:
Detailed medical history
Analysis of Exposure Diary
Any previous allergy tests
Foods suspected by the patient
Formulate diet to exclude all suspect allergens and intolerance triggers
Provide excluded nutrients from alternative sources
Duration: Usually four weeks
J.M.Joneja, Ph.D. 2013

56. Selective Elimination Diets
Certain conditions tend to be associated with specific food components
Suspect food components are those that are probable triggers or mediators of symptoms
Examples:
Eczema: Highly allergenic foods
Migraine: Biogenic amines
Urticaria/angioedema: Histamine
Chronic diarrhea: Carbohydrates; Disaccharides
Asthma: Cyclo-oxygenase inhibitors Sulphites
Latex allergy: Foods with structurally similar antigens to latex
Oral allergy syndrome: Foods with structurally similar antigens to pollens

57. Few Foods Elimination Diet
When it is difficult to determine which foods are suspects a few foods elimination diet is followed
Limited to a very small number of foods and beverages
Limited time: days for an adult
7 days maximum for a child
If all else fails use elemental formulae:
May use extensively hydrolysed formula for a young child

58. Expected Results of Elimination Diet
Symptoms often worsen on days 2-4 of elimination
By day 5-7 symptomatic improvement is experienced
Symptoms disappear after days of exclusion
J.M.Joneja, Ph.D. 2013

59. Challenge Double-blind Placebo-controlled Food Challenge (DBPCFC)
Lyophilized (freeze-dried) food is disguised in gelatin capsules
Identical gelatin capsules contain a placebo (glucose powder)
Neither the patient nor the supervisor knows the identity of the contents of the capsules
Positive test is when the food triggers symptoms and the placebo does not

60. Challenge (continued)
Drawback of DBPCFC
Expensive in time and personnel
Capsule may not provide enough food to elicit a positive reaction
Patient may be allergic to gelatin in capsule
May be other factors involved in eliciting symptoms, e.g. taste and smell

61. Challenge (continued)
Single-blind food challenge (SBFC)
Supervisor knows the identity of the food; patient does not
Food is disguised in a strong-tasting “inert” food tolerated by the patient:
lentil soup
apple sauce
tomato sauce

62. Challenge Phase continued
Open food challenge
Sequential Incremental Dose Challenge (SIDC)
Each food component is introduced separately
Starting with a small quantity and increasing the amount according to a specific schedule
This is usually employed when the symptoms are mild, and the patient has eaten the food in the past without a severe reaction
Any food suspected to cause a severe or anaphylactic reaction should only be challenged in suitably equipped medical facility

63. Open Food Challenge
Each food or food component is introduced individually
The basic elimination diet, or therapeutic diet continues during this phase
If an adverse reaction to the test food occurs at any time during the test STOP.
Wait 48 hours after all symptoms have subsided before testing another food

64. Incremental Dose Challenge
Day 1: Consume test food between meals
Morning: Eat a small quantity of the test food
Wait four hours, monitoring for adverse reaction
If no symptoms:
Afternoon: Eat double the quantity of test food eaten in the morning
Evening: Eat double the quantity of test food eaten in the afternoon
J.M.Joneja, Ph.D. 2013

65. Incremental Dose Challenge (continued)
Day 2:
Do not eat any of the test food
Continue to eat basic elimination diet
Monitor for any adverse reactions during the night and day which may be due to a delayed reaction to the test food
J.M.Joneja, Ph.D. 2013

66. Incremental Dose Challenge (continued)
Day 3:
If no adverse reactions experienced
Proceed to testing a new food, starting Day 1
If the results of Day 1 and/or Day 2 are unclear :
Repeat Day 1, using the same food, the same test protocol, but larger doses of the test food
Day 4:
Monitor for delayed reactions as on Day 2
J.M.Joneja, Ph.D. 2013

67. Sequential Incremental Dose Challenge
Continue testing in the same manner until all excluded foods, beverages, and additives have been tested
For each food component, the first day is the test day, and the second is a monitoring day for delayed reactions

68. Maintenance Diet

69. Final Diet
Must exclude all foods and additives to which a positive reaction has been recorded
Must be nutritionally complete, providing all macro and micro-nutrients from non-allergenic sources
There is no benefit from a rotation diet in the management of food allergy
A rotation diet may be beneficial when the condition is due to dose-dependent food intolerance
J.M.Joneja, Ph.D. 2013

70. IMPORTANT NUTRIENTS IN COMMON ALLERGENS
Minerals
Milk
Egg
Peanut
Tree
Nuts
Seeds
Soy
Fish
Shell
fish
Wheat
Corn
Calcium +
Phosphorus
Iron
Zinc
Magnesium
Selenium
Potassium
Molybdenum
Chromium
Copper
Manganese

71. Vitamins
Milk
Egg
Peanut
Nuts
Seeds
Soy
Fish
Shellfish
Wheat
Corn A +
Biotin
Folate
Thiamin
Riboflavin
Niacin
Pantothenic acid
B6 (Pyridoxine)
B12 D E K

72. Summary Food Allergy: Immune system response Food Intolerance:
Usually metabolic dysfunction
Diagnostic Laboratory Tests:
Often ambiguous because different physiological mechanisms are involved in triggering symptoms
J.M.Joneja, Ph.D. 2013

73. Summary
Reliable tests for the detection of adverse reactions to foods:
 Elimination and Challenge
Final diet
Must provide complete nutrition while avoiding all of the foods and food components that elicit symptoms on challenge