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Slide 2 - 2 Food Allergy & Food Intolerance DEFINITIONS: Food Allergy An immunologic reaction resulting from the ingestion of a food or food additive Food Intolerance A generic term describing an abnormal physiological response to an ingested food or food additive which is not immunogenic
Slide 3 - 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
Slide 4 - 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
Slide 5 - 5 Examples of Allergic Conditions and Symptoms Digestive Tract Diarrhea Constipation Nausea and Vomiting Abdominal bloating and distension Abdominal pain Indigestion (heartburn) Belching
Slide 6 - 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)
Slide 7 - 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
Slide 8 - 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
Slide 9 - 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
Slide 10 - 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
Slide 11 - 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 Egg Wheat Chicken
Slide 12 - 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
Slide 13 - 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
Slide 14 - 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)
Slide 15 - 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
Slide 16 - 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
Slide 17 - Tests for Adverse Reactions to Foods Rationale and Limitations
Slide 18 - 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
Slide 19 - 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
Slide 20 - 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
Slide 21 - 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
Slide 22 - 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
Slide 23 - 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
Slide 24 - 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
Slide 25 - 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
Slide 26 - 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)
Slide 27 - 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
Slide 28 - Non-IgE-Mediated Allergies Eosinophilic Gastrointestinal Diseases Food Protein Induced Enteropathies
Slide 29 - 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).
Slide 30 - 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
Slide 31 - 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)
Slide 32 - 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
Slide 33 - 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
Slide 34 - 34 Eosinophilic Esophagitis Foods most frequently implicatedin Children
Slide 35 - 35 Six-Food Elimination Diet and EoEAdult study 2013 Foods eliminated: Cereals Wheat Rice Corn Milk and milk products Eggs Fish and seafood Legumes including peanuts Soy Lucendo et al 2013
Slide 36 - 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
Slide 37 - 37 Eosinophilic Gastroenteritis:Diagnosis by biopsy:Abnormal number of eosinophils in the stomach and small intestineFoods most frequently implicated
Slide 38 - 38 Eosinophilic ProctocolitisDiagnosis by biopsy:Abnormal number of Eosinophils confined to the colonFoods most frequently implicated Cow’s milk Soy proteins Most frequently develops within the first 60 days of life Is a non-IgE-mediated condition
Slide 39 - 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
Slide 40 - 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)
Slide 41 - 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
Slide 42 - 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
Slide 43 - 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
Slide 44 - 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
Slide 45 - 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
Slide 46 - 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
Slide 47 - 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
Slide 48 - 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
Slide 49 - 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
Slide 50 - Elimination and Challenge Protocols
Slide 51 - 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
Slide 52 - 52 Food Intolerance: Clinical Diagnosis Elimination Diet: Avoid Suspect Food
Slide 53 - 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
Slide 54 - 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?
Slide 55 - 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
Slide 56 - 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
Slide 57 - 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: 10-14 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
Slide 58 - 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 10-14 days of exclusion
Slide 59 - 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
Slide 60 - 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
Slide 61 - 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
Slide 62 - 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
Slide 63 - 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
Slide 64 - 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 Wait four hours, monitoring for adverse reaction If no symptoms: Evening: Eat double the quantity of test food eaten in the afternoon
Slide 65 - 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
Slide 66 - 66 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 Incremental Dose Challenge (continued)
Slide 67 - 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
Slide 68 - Maintenance Diet
Slide 69 - 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
Slide 71 - 71
Slide 72 - 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
Slide 73 - 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