© 2004, 2002 Elsevier Inc. All rights reserved. Chapter 32 Medical Nutrition Therapy for Food Allergy and Food Intolerance © 2004, 2002 Elsevier Inc. All rights reserved.

Food Allergies—Cause Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

© 2004, 2002 Elsevier Inc. All rights reserved. Food Allergies—Pathophysiology Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

© 2004, 2002 Elsevier Inc. All rights reserved. Food Allergies—Medical and Nutritional Management Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

© 2004, 2002 Elsevier Inc. All rights reserved. Key Terms n Adverse food reaction —Any undesired response to a food regardless of mechanism n Food allergy (hypersensitivity) —Adverse food reaction that occurs consistently after ingestion, inhalation, and/or touch of a particular food, causing functional changes in target organs n Food intolerance —Adverse reaction to a food caused by toxic, pharmacologic, metabolic, or idiosyncratic reactions to the food or chemical substances in the food n Adverse food reaction —Any undesired response to a food regardless of mechanism n Food allergy (hypersensitivity) —Adverse food reaction that occurs consistently after ingestion, inhalation, and/or touch of a particular food, causing functional changes in target organs n Food intolerance —Adverse reaction to a food caused by toxic, pharmacologic, metabolic, or idiosyncratic reactions to the food or chemical substances in the food

© 2004, 2002 Elsevier Inc. All rights reserved. Immune System n Humoral immunity —Involves antibodies n Cellular immunity —Involves the action of T lymphocytes (T cells) n Humoral immunity —Involves antibodies n Cellular immunity —Involves the action of T lymphocytes (T cells)

© 2004, 2002 Elsevier Inc. All rights reserved. Important Terms n Allergy n Allergens/antigen n Antibodies/immunoglobulins n B lymphocytes n T lymphocytes n Macrophages n Allergy n Allergens/antigen n Antibodies/immunoglobulins n B lymphocytes n T lymphocytes n Macrophages

© 2004, 2002 Elsevier Inc. All rights reserved. Types of Allergic Reactions n Type I—immediate hypersensitivity involves IgE binding to the allergen n Type II—cytotoxic; not food related n Type III—a complex of the antigen and antibody form; slow reaction n Type IV—T cells interact with the antigen as in graft rejection n Type I—immediate hypersensitivity involves IgE binding to the allergen n Type II—cytotoxic; not food related n Type III—a complex of the antigen and antibody form; slow reaction n Type IV—T cells interact with the antigen as in graft rejection

© 2004, 2002 Elsevier Inc. All rights reserved. Symptoms of Food Allergy

© 2004, 2002 Elsevier Inc. All rights reserved. Risk for Development of Food Allergy n Heredity n Exposure to a food (antigen) n Gastrointestinal permeability n Amount of antigen plus environmental factors—exposure plus environment (pollen, smoke, etc.) n Heredity n Exposure to a food (antigen) n Gastrointestinal permeability n Amount of antigen plus environmental factors—exposure plus environment (pollen, smoke, etc.)

© 2004, 2002 Elsevier Inc. All rights reserved. How Does a Reaction Occur? n Once a person becomes sensitized, ingestion of milligram quantities of food allergens may be enough to trigger an allergic reaction. n After IgE antibodies are produced, they circulate in the blood and bind to the surface of body cells called “mast cells.” This triggers a complex series of reactions. n Once a person becomes sensitized, ingestion of milligram quantities of food allergens may be enough to trigger an allergic reaction. n After IgE antibodies are produced, they circulate in the blood and bind to the surface of body cells called “mast cells.” This triggers a complex series of reactions.

© 2004, 2002 Elsevier Inc. All rights reserved. How Does a Reaction Occur?—cont’d n Release of histamine and other mediators occurs rapidly, within 5 minutes after the interaction between the allergen and the IgE antibody on the surface of the mast cell. n Once released, they enter the bloodstream and bind to “receptors” on other cells. n The severity of the allergic reaction to a food depends primarily on how sensitized the person is and the amount of allergenic food that was eaten. n Release of histamine and other mediators occurs rapidly, within 5 minutes after the interaction between the allergen and the IgE antibody on the surface of the mast cell. n Once released, they enter the bloodstream and bind to “receptors” on other cells. n The severity of the allergic reaction to a food depends primarily on how sensitized the person is and the amount of allergenic food that was eaten.

© 2004, 2002 Elsevier Inc. All rights reserved. How Does a Reaction Occur?—cont’d n Food-sensitive people who have experienced more than one allergic reaction usually report the same early warning signs and symptoms with each reaction. n Treatment of food-induced allergic reactions is directed at several points in the series of events. n Food-sensitive people who have experienced more than one allergic reaction usually report the same early warning signs and symptoms with each reaction. n Treatment of food-induced allergic reactions is directed at several points in the series of events.

© 2004, 2002 Elsevier Inc. All rights reserved. Concerns for Infants and Young Children n In studies of the incidence of cow’s milk, protein allergy in infancy has been estimated at about 2% to 3%. n Allergic reactions are also frequently observed against egg white, fish, cereals, nuts, peanuts, and soybeans that are found in breast milk. n In studies of the incidence of cow’s milk, protein allergy in infancy has been estimated at about 2% to 3%. n Allergic reactions are also frequently observed against egg white, fish, cereals, nuts, peanuts, and soybeans that are found in breast milk.

© 2004, 2002 Elsevier Inc. All rights reserved. Concerns for Infants and Young Children —cont’d n Exclusive breast-feeding with exclusion of cow’s milk formulas and complementary foods during the first 4 to 6 months has a preventive effect against allergic symptoms, extending beyond the period of breast-feeding. n Formulas based on soy protein are not recommended for the prevention of food allergy. n Exclusive breast-feeding with exclusion of cow’s milk formulas and complementary foods during the first 4 to 6 months has a preventive effect against allergic symptoms, extending beyond the period of breast-feeding. n Formulas based on soy protein are not recommended for the prevention of food allergy.

© 2004, 2002 Elsevier Inc. All rights reserved. Concerns for Infants and Young Children —cont’d n Breast-fed infants who have developed allergy to cow’s milk are shown to have been given cow’s milk formula in the nursery shortly after birth, prior to starting breast-feeding. n This early “bottle” of cow’s milk formula may have led to initial sensitization to cow’s milk n Breast-fed infants who have developed allergy to cow’s milk are shown to have been given cow’s milk formula in the nursery shortly after birth, prior to starting breast-feeding. n This early “bottle” of cow’s milk formula may have led to initial sensitization to cow’s milk

© 2004, 2002 Elsevier Inc. All rights reserved. Symptoms of Food Allergies n Gastrointestinal manifestations n Cutaneous manifestations n Respiratory manifestations n Systemic manifestations n Controversial or unproven manifestations n Gastrointestinal manifestations n Cutaneous manifestations n Respiratory manifestations n Systemic manifestations n Controversial or unproven manifestations

© 2004, 2002 Elsevier Inc. All rights reserved. Do Fruits and Vegetables Cause Reactions? Role of Oral Allergy Syndrome n Oral allergy syndrome (OAS)—caused by cross-reacting or identical allergens that are present in both the pollen and fresh food n Symptoms—itching or swelling of the lips, tongue, throat, or roof of the mouth. They are less severe if the individual is receiving regular doses of antihistamines. n Oral allergy syndrome (OAS)—caused by cross-reacting or identical allergens that are present in both the pollen and fresh food n Symptoms—itching or swelling of the lips, tongue, throat, or roof of the mouth. They are less severe if the individual is receiving regular doses of antihistamines.

© 2004, 2002 Elsevier Inc. All rights reserved. n Vegetables—carrots, celery, parsley, potato, tomato n Seeds and nuts—fennel seed, hazelnut (filbert), sunflower seeds n Fruits—apple, apricot, banana, cantaloupe, cherry, honeydew, orange, peach, pear, watermelon Foods Associated with Oral Allergy Syndrome

© 2004, 2002 Elsevier Inc. All rights reserved. Treatment of Oral Allergy Syndrome n Not much is known, but some researchers report that both hay fever symptoms and OAS symptoms go away if the affected person receives immunotherapy injections with extracts of cross-reacting pollens.

© 2004, 2002 Elsevier Inc. All rights reserved. Symptoms of Milk-Allergic Children n Hives and itching (skin) n Wheezing n Coughing n Severe nasal symptoms (respiratory tract) n Vomiting and/or diarrhea (gastrointestinal tract) n Hives and itching (skin) n Wheezing n Coughing n Severe nasal symptoms (respiratory tract) n Vomiting and/or diarrhea (gastrointestinal tract)

© 2004, 2002 Elsevier Inc. All rights reserved. Atopic Eczema Fig. p..

© 2004, 2002 Elsevier Inc. All rights reserved. Growing Out of Food Allergies n Approximately 85% of young children with allergies become tolerant of the foods by age 3. n It is rare to find these allergies in adults. n Allergies to peanuts, tree nuts, fish, and shellfish are not easily outgrown. n Approximately 85% of young children with allergies become tolerant of the foods by age 3. n It is rare to find these allergies in adults. n Allergies to peanuts, tree nuts, fish, and shellfish are not easily outgrown.

© 2004, 2002 Elsevier Inc. All rights reserved. Diagnosis n History—family history, early feeding history n Physical examination—malnutrition, eczema, rhinitis, asthma n Biochemical testing—R/O other conditions n Food elimination—confirm a food allergy n Food challenge—once symptom free, reintroduce one food at a time n History—family history, early feeding history n Physical examination—malnutrition, eczema, rhinitis, asthma n Biochemical testing—R/O other conditions n Food elimination—confirm a food allergy n Food challenge—once symptom free, reintroduce one food at a time

© 2004, 2002 Elsevier Inc. All rights reserved. Diagnosis—cont’d Food and symptom diary —Quantity —Time from ingestion to symptoms —Symptoms —Symptoms every time food ingested Food and symptom diary —Quantity —Time from ingestion to symptoms —Symptoms —Symptoms every time food ingested

© 2004, 2002 Elsevier Inc. All rights reserved. Diagnostic Tests n Immunologic testing —Skin-prick —RAST: radioallergosorbent test —ELISA: enzyme-linked immunosorbent assay —FEIA —Cytotoxic testing —Sublingual testing —Provocation testing and neutralization —Kinesiologic testing n Immunologic testing —Skin-prick —RAST: radioallergosorbent test —ELISA: enzyme-linked immunosorbent assay —FEIA —Cytotoxic testing —Sublingual testing —Provocation testing and neutralization —Kinesiologic testing

© 2004, 2002 Elsevier Inc. All rights reserved. Skin-Prick Test Fig.. p..

© 2004, 2002 Elsevier Inc. All rights reserved. Treatment n Elimination diet —Investigational short-term or possible lifelong eating plan that omits one or more foods suspected or known to cause an adverse food reaction or allergic response n Elimination diet —Investigational short-term or possible lifelong eating plan that omits one or more foods suspected or known to cause an adverse food reaction or allergic response

© 2004, 2002 Elsevier Inc. All rights reserved. Treatment—cont’d n Avoid the food n Nutritional counseling —Hidden forms of the food —Replace nutrients missing n Retest for allergy every 1 to 3 months (children grow out of the allergies) n Avoid the food n Nutritional counseling —Hidden forms of the food —Replace nutrients missing n Retest for allergy every 1 to 3 months (children grow out of the allergies)

© 2004, 2002 Elsevier Inc. All rights reserved. Treatment—cont’d n Careful food selection for common allergies n Infants —Breast milk (mother avoids allergenic foods and foods that cause infant gastrointestinal distress) —Cow’s milk allergy infants need casein hydrosylate formula rather than soy. —Goat’s milk is not usually a good choice. n Careful food selection for common allergies n Infants —Breast milk (mother avoids allergenic foods and foods that cause infant gastrointestinal distress) —Cow’s milk allergy infants need casein hydrosylate formula rather than soy. —Goat’s milk is not usually a good choice.

© 2004, 2002 Elsevier Inc. All rights reserved. Reasons That Allergens May Contaminate a Food n Same utensils used to serve different foods n Same equipment used to manufacture different foods n Misleading labels n Ingredients listed in terms of purpose instead of ingredient n Addition of allergenic product to second product that bears a label only listing ingredients of second product (mayonnaise) n Same utensils used to serve different foods n Same equipment used to manufacture different foods n Misleading labels n Ingredients listed in terms of purpose instead of ingredient n Addition of allergenic product to second product that bears a label only listing ingredients of second product (mayonnaise)

© 2004, 2002 Elsevier Inc. All rights reserved. Strategies for Coping with Food Allergy

© 2004, 2002 Elsevier Inc. All rights reserved. Strategies for Coping with Food Allergy —cont’d

© 2004, 2002 Elsevier Inc. All rights reserved. Foods Known to Cross-React in Latex Allergy

© 2004, 2002 Elsevier Inc. All rights reserved. Development of New Allergies n The development of a specific food allergy depends upon prior exposure to that food. n It is uncertain how and why adults can, for no apparent reason, develop an allergy to a food eaten many times before. n It is also uncertain if these reactions will lessen or disappear over time. n The development of a specific food allergy depends upon prior exposure to that food. n It is uncertain how and why adults can, for no apparent reason, develop an allergy to a food eaten many times before. n It is also uncertain if these reactions will lessen or disappear over time.

© 2004, 2002 Elsevier Inc. All rights reserved. Migraines n Females are greater than 3 times more likely to experience migraines than males. n People of both sexes who suffer from migraines are much more likely than those who do not to report food allergies n Females are greater than 3 times more likely to experience migraines than males. n People of both sexes who suffer from migraines are much more likely than those who do not to report food allergies

© 2004, 2002 Elsevier Inc. All rights reserved. Colic n Sleeplessness and irritability n Not usually an allergy n Sleeplessness and irritability n Not usually an allergy

© 2004, 2002 Elsevier Inc. All rights reserved. Food Intolerances n Additives n Sulfites n Lactose n Additives n Sulfites n Lactose

© 2004, 2002 Elsevier Inc. All rights reserved. Food Labeling n The US Food and Drug Administration (FDA) is striving to improve labeling of snack foods that contain allergens. n A study found undisclosed traces of peanuts in a quarter of all snacks tested. n Such trace amounts may be due to cross contamination, in which utensils used in making one product are used in another. n The US Food and Drug Administration (FDA) is striving to improve labeling of snack foods that contain allergens. n A study found undisclosed traces of peanuts in a quarter of all snacks tested. n Such trace amounts may be due to cross contamination, in which utensils used in making one product are used in another.

© 2004, 2002 Elsevier Inc. All rights reserved. Additives n Food and food additive allergies: —Egg allergy and its potential cross- reaction with the influenza vaccine —Peanut and tree nut allergies n An awareness of these issues will help primary providers identify these patients earlier, thereby avoiding repeated ingestion of these allergens. n Food and food additive allergies: —Egg allergy and its potential cross- reaction with the influenza vaccine —Peanut and tree nut allergies n An awareness of these issues will help primary providers identify these patients earlier, thereby avoiding repeated ingestion of these allergens.

© 2004, 2002 Elsevier Inc. All rights reserved. Regulations n Tighter regulations may be forthcoming. n It’s unlikely that the FDA will be able to inspect all food manufacturers to enforce such rules. n The administration is issuing new guidelines to its investigators to help them pinpoint and tackle problem manufacturers. n Tighter regulations may be forthcoming. n It’s unlikely that the FDA will be able to inspect all food manufacturers to enforce such rules. n The administration is issuing new guidelines to its investigators to help them pinpoint and tackle problem manufacturers.

© 2004, 2002 Elsevier Inc. All rights reserved. Prevention In high-risk infants n Mother should breast-feed and avoid typically allergenic foods. n Wait until 2 to 3 yrs of age to introduce milk, egg, peanuts, fish. In high-risk infants n Mother should breast-feed and avoid typically allergenic foods. n Wait until 2 to 3 yrs of age to introduce milk, egg, peanuts, fish.