Medical Nutrition Therapy for Food Allergies

1. Medical Nutrition Therapy for Food Allergies Camille McGoven Concordia College, Moorhead, MN

2. Objectives • To be able to identify common food allergies and differentiate from other similar diseases. • Understand causes, preventative measures, and treatments for food allergies. • Gain competency on how to diagnose a patient correctly. • Gain understanding of specific nutritional implications for children with food allergies. • Understand the role of the dietitian and importance of cooperation with allergist or physician.

3. Food Allergy • American Dietetics Association: “Food allergies are abnormal responses of the body’s immune system to certain foods or food ingredients.” • Role of dietitian: • Teach patient how to make living with a food allergy easier and more manageable with practical goals. • Develop a meal plan that fits the patient’s needs. • Effective communication with allergist and other medical practitioners to determine best fit plan of care for patient. Dietitians face the challenge of food allergies. Journal of the American Dietetic Association. 2000; 100:1.

4. Background • 30-35% Americans believe they have a food allergy.¹ • 8% of children and 2% of adults are reported to have a diagnosed food allergy. ¹ • Frequently, food allergies coincide with additional allergic diseases such as eczema (atopic dermatitis) and asthma.² ¹Long S & Nelms M, & Sucher, K. (2007). Nutrition Therapy and Pathophysiology. United States: Thompson Brooks/Cole. ²Food Allergy: Report of the National Institute of Health Expert Panel on Food Allergy Research. (2006). National Institute of Allergy and Infectious Diseases. Retrieved September 10, 2009. <http://www3niaid.nih.gov/topics/foodAllergy/research/ReportFoodAllergy.htm>.

5. Background • 35-50% of emergency room visits for anaphylaxis are from food allergies. • Food allergies are the cause of 30,000 occurrences of anaphylaxis and 100-200 deaths in the United States/year. • No known cure for food allergies. • Food allergies appear to be increasing, especially in Western countries. Food Allergy: Report of the National Institute of Health Expert Panel on Food Allergy Research. (2006). National Institute of Allergy and Infectious Diseases.Retrieved September 10, 2009. <http://www3niaid.nih.gov/topics/foodAllergy/research/ReportFoodAllergy.htm>.

6. What is a food allergy? • Immunologically based abnormal response to a protein in a food • Type I or IgE allergy • IgE- (immunoglobulin E) class that is the main mediator for immediate hypersensitivity reactions; allergies. • Characterized by hypersensitivity- an inappropriate and harmful immune reaction to a harmless, non pathogenic substance; “allergy.” • Food allergy is called an immediate hypersensitivity because reaction usually occurs within minutes to 2 hours.

7. What is a food allergy? • Most often, person has an inherited predisposition • Race and gender have shown no impact on food allergy prevalence. • The immune system is responsible for the food allergy response. • Symptoms can be triggered by a small portion of food, and an allergic reaction will occur every time the food is eaten.

8. >160 different foods can cause allergic reactions in people with food allergies 8 foods responsible for 90% of allergic reactions: Milk Eggs Soy Peanuts Tree nuts (cashews, almonds) Wheat Fish Shellfish Adult Most Common Peanuts Shellfish Fish Tree Nuts Children Most Common Peanuts Shellfish Soy Tree nuts Wheat Cow’s milk- occurs more often with a family history of allergy Common Food Allergies Henochowicz, S. Food Allergy. (2009). Medline Plus Medical Encyclopedia. Retrieved September 16, 2009. <http://www.nlm.nih.gov/medlineplus/ency/article/000817.htm>.

9. Common Symptoms Swelling of lips, face, tongue Itchy eyes Rash/hives-most common symptom Throat tightness Rasping cough Runny nose Wheezing or asthma Abdominal pain Nausea Vomiting Diarrhea Anaphylaxis Most severe allergic reaction Effects the whole body- lungs are major target Histamine leads to constriction of airways Difficulty breathing Blood vessel dilation Lower blood pressure Fluid leakage, from bloodstream to tissues Leads to shock, hives, GI symptoms Food Allergy- Symptoms

10. Anaphylaxis / Hives Henochowicz, S. Food Allergy. (2009). Medline Plus Medical Encyclopedia. Retrieved September 16, 2009. <http://www.nlm.nih.gov/medlineplus/ency/article/000817.htm>.

11. Pathophysiology • Certain foods will trigger immune response- IgE response to proteins that cross the GI lining. • Initial exposure causes sensitization, and re-exposure will cause allergic reaction. • Antibodies, IgE, respond to the allergen (from the certain food). • IgE binds to surface of two types of cells: • Mast cells – present in the tissues • Basophils- present in the blood • Allergen binds to the IgE on the surfaces of the mast cells and basophiles. • Binding then triggers the cells to release specific mediators of allergic reaction: histamine, leukotrienes (inflammation), and cytokines (protein messengers) • Mediators stimulate: • Eosinophils- WBC, characteristic of allergic inflammation • Allergic reaction symptoms

12. Type 1 involves IgE antibodies, which attach to mucus membranes which release histamine. Allergic reactions usually occur within 1 to 60 minutes. They cause classic symptoms, such as: asthma, rhinitis, (running nose), eczema, hives, red cheeks, etc. It is the most dangerous, and can be life threatening. Power, Laura. Food Allergies. (2006). Retrieved October 8, 2009 from < www.biotype.net/diets/foodallergies.htm>.

13. Pathophysiology- Histamine High levels of IgE antibodies in response to food will predict likelihood of allergic reaction, but not reaction severity. • In response to allergy, histamine will cause: • Leakage of fluid from small blood vessels into tissues • Smooth muscles contract- depending on where the muscles contract, different reactions will occur • Mild allergic reaction, only small amount of fluid leakage can lead to hives in the skin • Severe reaction, large fluid leakage can lead to blood pressure drop • Smooth Muscle contraction in larynx and trachea will cut off air flow • Smooth Muscle contraction in lungs causes bronchoconstriction and wheezing

14. Peanut Allergy • Less than 21% of those with peanut allergies will out grow the allergy. • Food allergies appear to be increasing, especially peanut allergies. • Study- The Worm and Peanuts • Possibly the allergy is caused by a misdirection of the immune system, which evolved from protecting the body from worms (hookworms, pinworms, roundworms, flukes). • Early introduction or restriction? • Israel has much lower occurrence of peanut allergy (<.1%) than in Western countries including the U.S. (1%) • Peanut snack introduced into infants diet at 6-7 months • Current recommendations for all complementary food introduction according to Pediatrics is 4-6 months, however many resources claim that common food allergy foods should be introduced later, which could actually be causing the food allergy. Greer FR, Sicherer SH, Burks AW, Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods,and Hydrolyzed Formulas. Pediatrics. 2008; 121:183-191. Long S & Nelms M, & Sucher, K. (2007). Nutrition Therapy and Pathophysiology. United States: Thompson Brooks/Cole

15. Oral Allergy Syndrome • Cross-reaction, not food allergy • Certain pollen allergies – Fruits and vegetables in the same botanical family as the plant allergen will cause allergic reaction • Example- ragweed allergy- allergic reaction to cantaloupe, watermelon, honeydew • Symptoms: • Only causes tingling, itching or swelling in the mouth (symptoms occur all over the body for food allergies) • Reaction will disappear if food is cooked (food allergies will persist even within cooked foods)

16. Food intolerance • Some symptoms can mimic those of food allergies • Nausea, stomach pain, gas, cramps or bloating, vomiting, heartburn, diarrhea, headaches, irritability/nervousness • Immune system plays no role in intolerances. • Digestive system response • Symptoms not always immediate, may only occur when large portions of food are consumed • Intolerance reactions can be caused by: • Chemical ingredients added to foods- color, flavor enhancement, protect against bacteria growth • Example: Monosodium glutamate (MSG) • Histamine or in cheese, wines and fish (tuna, mackerel) • Digestive system unable to properly digest foods • Example: Lactase deficiency- most common intolerance

17. Celiac Disease • Inflammation of the small intestine caused by gluten found in grains, including wheat, rye, malt, barley, and oats. • Etiology- both genetic and autoimmune • Toxic, inflammatory response when small intestinal mucosa is exposed to certain amino acid sequences found in the protein portion of gluten • Damaged villi- height is reduced and appear flatter • Malabsorption and maldigestion • Symptoms could be confused for a food allergy • Diarrhea, abdominal pain, cramping, bloating, gas production • Gluten-free diet

18. Food Allergy Causes • Usually person is genetically predisposed to certain proteins in foods. • “Hygiene Hypothesis”¹ • Increase in vaccines, reduction of disease, and increase in overall hygiene could contribute to food allergies as well as other allergic diseases. • Because of a lack of exposure to environmental viruses and parasites, the allergic state may develop, the immune system develops differently and the IgE will respond instead to harmless proteins, such as food proteins. ¹ Helm, Ricki M, Burks, Wesley A. Mechanisms of Food Allergy. Current Opinion in Immunology. 2000;12:6.

19. Causes • Study: Italian Air Force Cadets • Tested exposure to air-born viruses, orofecal, or food-borne illnesses • Those with no exposure, 3x more likely to have allergies than those that had been previously exposed. • However, still conflicting studies¹ • Obesity • Visness et al studied youth 2-19 years old using the National Health and Nutrition Examination Survey data from 2005-2006 • NHANES data included total IgE levels and allergy questions • Used BMI as standard for obesity, 95th percentile or greater • Found that children who were considered overweight tended to also have an allergic predisposition to food. ² ¹Helm, Ricki M, Burks, Wesley A. Mechanisms of Food Allergy. Current Opinion in Immunology. 2000;12:6. ² Visness CM, London SJ, Daniels JL, Kaufman JS, Yeatts KB, Siega-Riz A, Liu AH, Calatroni A, Zeldin DC. Obesity and Allergy:Association of obesity with IgE levels and allergy symptoms in children and adolescents: Results from the National Health and Nutrition Examination Survey 2005-2006. 2008.

20. Diagnosis • No single lab test can diagnose. • Tests (doctor or allergist) • CAP System fluorescent-enzyme immunoassay (FEIA)- blood sample • Radioallergosorbent (RAST) test- blood sample • Skin prick test- drop of food extract put on skin, and then skin is pricked • Food Challenges • Open, single-blind, double-blind and placebo controlled • Detailed diet History (dietitian) • Used to locate possible allergens within patient’s diet Dietitians face the challenge of food allergies. Journal of the American Dietetic Association. 2000; 100:1.

21. Diagnosis • Trial Elimination Diet • Recommended if patient tests positive in the RAST or skin prick test • Avoid the possible food allergy until symptoms disappear • Foods are reintroduced to see if they cause allergic reaction • Used if certain food tested by allergist comes up as positive, and is indicated as a possible allergen from diet history. • Food Diary • Used to monitor client’s food records for possible hidden sources of food allergy

22. Food Diary Dietitians face the challenge of food allergies. Journal of the American Dietetic Association. 2000; 100:1.

23. Sample Food Allergy Meal Plan FIG 1. Sample menu eliminating all major food allergens from the diet for a school-aged child: peanuts, tree nuts, milk, soy, wheat, egg, fish, and shellfish. Reprinted from: Food Allergies, c 1998 The American Dietetic Association. Dietitians face the challenge of food allergies. Journal of the American Dietetic Association. 2000; 100:1.

24. Treatments • Antihistamines • Effective in treating mild allergic reactions- hives • Less effective in severe reactions due to much higher levels of histamine • Epinephrine • Causes a reversal effect on mediators on blood vessels and smooth muscle and of histamine • Blocks further release of mediators from the basophiles and mast cells

25. Future Treatments • Probiotics • “Live microorganisms which when administered in adequate amounts confer a health benefit on the host.” • Many studies show benefits for atopic dermatitis, new studies are to be focused on food allergies • Study reported by Zuercher et al • 230 babies,<12 months with cow’s milk allergy • Randomized to receive either Lactobacillus rhamnosus strain GG (LGG), mix of LGG and 3 additional probiotics, placebo for 4 weeks • 4 weeks after treatment end, tested for symptoms of allergy, mainly eczema • Significant difference between LGG and placebo group, as long as allergy was IgE associated • Could help with alleviation of food allergy symptoms Zuercher AW, Fritsche R, Corthesy B, Mercenier A. Food products and allergy development, prevention and treatment. Current Opinion in Biotechnology. 2006; 17:198-203.

26. Future Treatments • Monoclonal antibodies • Bind to human IgE • Lower IgE levels and number of receptors on mast cells, basophiles • Omalizumab- FDA licensed for treatment of asthma • Study - patients with peanut allergies • High doses of antibodies increased threshold of peanut allergy reaction • 1.5 peanuts-9 peanuts • Important for accidental exposure Food Allergy. Report of the NIH Panel on Food Allergy Research. (2006). National Institute of Allergy and Infectious Disease. Retrieved September 10, 2009.<http://www3.niaid.nig.gov/topics/foodAllergy/research/ReportFoodAllergy.htm>.

27. Future Treatments • Oral immunotherapy (OIT) • Allergen dose is swallowed in increasing increments over time, supposed to lead to food allergy tolerance • Staden et al- study of 25 milk or egg-allergic children • Dose escalation, maintenance dose, two-month period of allergen avoidance • All experienced mild allergic reactions (hives) • 36% of children remained tolerant to the eggs or milk as determined by food challenge • IgE levels decreased Staden U, Rolinck-Werninghaus C, Brewe F, Wahn U, Niggermann B, Beyer K. Specific oral tolerance induction in food allergy in children: efficacy and clinical patterns of reaction. Allergy. 2007. 122:418-419.

28. Future Treatments • Chinese Herbal Medicine • Nine Chinese herbs- FAHF-2 • Srivastava et al • Mice as models of peanut allergy treated with FAHF-2, 2 times per day for 6 weeks. • When exposed to peanuts, no evidence of anaphylaxis up to five weeks post treatment • Lower peanut-specific IgE levels than placebo group Srivastave KD, Kattan JD, Zou ZM, Li JH Zhang L, WallensteinS, Goldfarb J, Sampson HA, Li XM: The Chinese herbal medicine formula FAHF-2 completely blocks anaphylactic reactions in a murine model of peanut allergy. J Allergy Clin Immunol 2005, 115: 171-178.

29. Prognosis • No Known Cure. • Strict elimination of offending food from diet and being prepared for an allergic reaction can allow those with food allergies to live normal lives by eliminating foods causing allergies.

30. Prevention • Breast feeding- Could be beneficial for infants at high risk for allergic disease to prevent cow’s milk allergies and wheezing early in life.¹ • Breast feeding versus cow’s milk formula for four months for infants at risk for food allergy may help with preventing cow’s milk allergies until 2 years of age.² • However, Kramer et al - Reported that 4 months of breastfeeding would not prevent food allergy acquirement by one year of age.³ • However, important for mother to refrain from eating a diet high in certain foods which infant may be allergic to. ¹Greer FR, Sicherer SH, Burks AW, Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods,and Hydrolyzed Formulas. Pediatrics. 2008; 121:183-191. ²Muraro A, Dreborg S, Halken S, et al. Dietary prevention of allergic diseases in infants and small children. Part III : critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediar Allergy Immunol. 2004; 15:291-307. ³Kramer MS, Kakuma R. Optimal duration of exclusive breast-feeding. Cochrane Database Syst Rev. 2002;(1):CD003517.

31. Food Allergies and Children • Affects 3%-7% of young children¹ • 6/100 children have clinically documented food allergy¹ • 80%-90% outgrow allergy by 3 years old. ¹ • From 1997-2007 peanut allergies increased in the United States in children younger than 18 years old by 18%.² • Peanuts, shell fish, and tree nut allergy usually lifelong • Children with food allergies are about 2-4 times more likely to have additional allergic conditions and asthma. ² • Increased risk for severe allergic reactions- Anaphylaxis ¹Long S & Nelms M, & Sucher, K. (2007). Nutrition Therapy and Pathophysiology. United States: Thompson Brooks/Cole ² Branum AM, Lukacs SL. Food allergy among U.S. children: Trends in prevalence and hospitalizations.NCHS data brief, no 10. Hyattsville, MD: National Center for Health Statistics. 2008.

32. Food Allergies and Children Branum AM, Lukacs SL. Food allergy among U.S. children: Trends in prevalence and hospitalizations.NCHS data brief, no 10. Hyattsville, MD: National Center for Health Statistics. 2008.

33. Nutrition Implications • Children with two or more allergies, or a cow’s milk allergy are at risk for growth problems and inadequate nutrient intake.¹ • Major nutrients at risk: • Calcium • Vitamin D • Essential to monitor dietary intake and prevent poor oral intake to ensure adequate nutrient and calorie intake. • Important to educate and counsel patient on reading food labels to prevent allergy exposure. • Annual examination is recommended to monitor growth rate. ¹ Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. J of the American Dietetic Association. 2002; Number 11, 102:1648-1651.

34. Nutrition Implications • Children 1-3 years old • AI for Calcium ~ 500mg/day • AI for Vitamin D ~ 5 mcg/day • Children 4-8 years old • AI for Calcium ~800 mg/day • AI for Vitamin D ~ 5 mcg/day • Alternative Calcium and Vitamin D sources if he/she has milk allergy • Vitamin D • Eggs • Fortified orange juice, cereals, soy milk • Calcium • Calcium fortified orange juice, cereals, soy milk • Tofu fortified with calcium • Collard greens • White beans • Almonds

35. Nutrition Implications • Christie et al -Study investigating nutrient intake and growth in children with food allergies. • Subjects: 98 children with food allergies and 99 children without food allergies as control; ages between 1 and 5 years old. • Results: Children with 2 or more allergies were found to be shorter than those with one allergy • Children with cow’s milk allergy, or those who had multiple food allergies consumed less Calcium and Vitamin D than current recommendations. • Children/parents who received nutrition counseling or those who consumed safe formulas or soy beverages that were fortified were less likely to have a Calcium or Vitamin D deficiency • Implications: Essential to educate patient on alternative sources of Calcium and Vitamin D to ensure adequate nutrient intake, prevent osteoporosis, and achieve normal growth. • Essential to educate patient with multiple allergies on label reading and food sources containing food allergy to ensure adequate daily calorie intake. Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. J of the American Dietetic Association. 2002; Number 11, 102:1648-1651.

36. Assisting the patient • Encourage patient to discuss food allergies with others. • Explain importance of always having medication available at all times in case of emergency. • Help patient identify potential problems with allergy and develop a plan of action for situations. • Include the child in discussion about food allergies and their school plan when child is at 7 years or older • Encourage parents to contact schools so teachers and staff are informed of allergy. • Nursing staff • Cafeteria menus • Art class projects • Educate patient on reliable resources on food allergies: • American Academy of Allergy Asthma & Immunology (AAAAI), The American College of Allergy, Asthma and Immunology (ACAAI), The Food Allergy Network, www.quackwatch.com

37. Food Allergies and Regulations • FDA • Food Allergen Labeling and Consumer Protection Act (FALCPA) of 2004, enacted in 2006 • Identifies the 8 major food allergens: Milk, eggs, fish, crustacean shellfish, tree nuts, wheat, peanuts, soybeans • Plain language used: • Contains statement- “Contains milk” • Common or usual name followed by in parenthesis the food that the allergen is derived from- “natural flavoring [milk, eggs]” • Does not re-label products labeled prior to the FALCPA enactment in 2006 • Applies to imported products, except meat, poultry, and certain egg products Hahn M, McKnight M. Food Labeling: FDA Public Hearing on Advisory Labeling. (2009). The Food Allergy & Anaphylaxis Network. Retrieved on September 10, 2009.<http://www.foodallergy.org/Advocacy/labeling.html>.

38. Ethical Questions • Peanut free schools? • “Peanut-safe” tables lead to less incidences of accidental ingestion • Social isolation • Difficult to monitor • Food Challenges? • Can induce anaphylaxis • Can help determine tolerance levels

39. “The bottom line is that dietitians can help make living with a food allergy easier by identifying lifestyle needs, developing a practical approach to management, coordinating care, and maintaining realistic expectations.” • Celide Barnes Koerner, MS, RD, dietetic consultant for the Food Allergy Network

40. Questions?

41. References • Branum AM, Lukacs SL. Food allergy among U.S. children: Trends in prevalence and hospitalizations.NCHS data brief, no 10. Hyattsville, MD: National Center for Health Statistics. 2008. • Christie L, Hine RJ, Parker JG, Burks W. Food allergies in children affect nutrient intake and growth. J of the American Dietetic Association. 2002; Number 11, 102:1648-1651 • Dietitians face the challenge of food allergies. J of the American Dietetic Association. 2000; 100:1. • Food Allergy. Report of the NIH Panel on Food Allergy Research. (2006). National Institute of Allergy and Infectious Disease.Retrieved October 10, 2009. <http://www3.niaid.nig.gov/topics/foodAllergy/research/ReportFoodAllergy.htm>. • Greer FR, Sicherer SH, Burks AW, Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods,and Hydrolyzed Formulas. Pediatrics. 2008; 121:183-191. • Hahn M, McKnight M. Food Labeling: FDA Public Hearing on Advisory Labeling.(2009). The Food Allergy & Anaphylaxis Network. Retrieved September 10, 2009. <http://www.foodallergy.org/Advocacy/labeling.html>. • Helm, Ricki M, Burks, Wesley A. Mechanisms of Food Allergy. Current Opinion in Immunology. 2000;12:6. • Henochowicz, S. Food Allergy. Medline Plus Medical Encyclopedia.2009. Retrieved September 16, 2009. <http://www.nlm.nih.gov/medlineplus/ency/article/000817.htm>.

42. References • Kramer MS, Kakuma R. Optimal duration of exclusive breast-feeding. Cochrane Database Syst Rev. 2002;(1):CD003517. • Long S & Nelms M, & Sucher, K. (2007). Nutrition Therapy and Pathophysiology. United States: Thompson Brooks/Cole. • Muraro A, Dreborg S, Halken S, et al. Dietary prevention of allergic diseases in infants and small children. Part III : critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediar Allergy Immunol. 2004; 15:291-307. • Power, Laura. Food Allergies. (2006). Retrieved October 8, 2009 from < www.biotype.net/diets/foodallergies.htm>. • Skripak JM, Sampson HA. Towards a cure for food allergy. Current Opinion in Immunology. 2008; 20:690-696. • Srivastave KD, Kattan JD, Zou ZM, Li JH Zhang L, WallensteinS, Goldfarb J, Sampson HA, Li XM: The Chinese herbal medicine formula FAHF-2 completely blocks anaphylactic reactions in a murine model of peanut allergy. J Allergy Clin Immunol. 2005; 115: 171-178. • Staden U, Rolinck-Werninghaus C, Brewe F, Wahn U, Niggermann B, Beyer K. Specific oral tolerance induction in food allergy in children: efficacy and clinical patterns of reaction. Allergy. 2007. 122:418-419. • Visness CM, London SJ, Daniels JL, Kaufman JS, Yeatts KB, Siega-Riz A, Liu AH, Calatroni A, Zeldin DC. Obesity and Allergy: Association of obesity with IgE levels and allergy symptoms in children and adolescents: Results from the National Health and Nutrition Examination Survey 2005-2006. 2008. • Zuercher AW, Fritsche R, Corthesy B, Mercenier A. Food products and allergy development, prevention and treatment. Current Opinion in Biotechnology. 2006; 17:198-203