Accommodating and Educating Students with Food Allergy

1. Accommodating and Educating Students with Food Allergy Marion Groetch, MS, RD Director, Nutrition Services marion.groetch@mssm.edu Jaffe Food Allergy Institute Mount Sinai School of Medicine New York, New York

2. Learning Objectives Define the difference between food allergy and food intolerance. Describe the steps involved in the allergy evaluation. Acquire the skills and identify resources to provide comprehensive education for allergen elimination diets. Understand the nutritional risks of allergen elimination diets. Identify resources for Job Corps food service staff, nurses and center personnel.

3. Guidelines for the Diagnosis and Management of FA in the US:NIAID-Sponsored Expert Panel Report Based on comprehensive review and objective evaluation of the recent scientific and clinical literature on FA. Working with more than 30 professional organizations, federal agencies and patient advocacy groups led the development of “best practice” clinical guidelines. Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58

4. Definition of Food Allergy (FA) Food allergy An adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food Food intolerance An untoward response to food substance that is not immunologically mediated

5. Food Allergies Can Be Life-Threatening • More people die each year from food allergy-induced reactions than to reactions to insect stings. • Food allergy is believed to cause an estimated 30,000 emergency department visits each year in the US. • The potential severity of a food allergic reaction cannot be predicted. Once a reaction begins, there is no way of predicting how severe it may become.

6. Anaphylaxis Allergic reaction that occurs most commonly within minutes (but can be up to several hours) after contact with an allergy causing substance. A serious allergic reaction that is rapid in onset and may cause death. Epinephrine is the first line treatment in all cases of anaphylaxis.

8. Food Allergy Anaphylaxis Oral Allergy Syndrome Immediate gastrointestinal allergy Asthma/rhinitis Urticaria Morbilliform rashes and flushing Contact urticaria Immunologic Non-Immunoglobulin E Mediated Cell-Mediated Immunoglobulin E (IgE) -Mediated (most common) • Protein-Induced Enterocolitis • Protein-Induced Enteropathy • Allergic proctitis • Dermatitis herpetiformis • Contact dermatitis • Eosinophilic esophagitis • Eosinophilic gastritis • Eosinophilic gastroenteritis • Atopic dermatitis Sampson H. J Allergy Clin Immunol 2004;113:805-9, Chapman J et al. Ann Allergy Asthma & Immunol 2006;96:S51-68.

9. Diagnosis of IgE-Mediated Food Allergy • Role of the primary care physician or Board Certified Allergist • Detailed medical and dietary history with a focus on symptoms • Identify general approach • Allergy vs. intolerance • IgE vs. non-IgE • Thorough physical exam • Diagnostic tests to rule out other medical conditions not related to food allergy

10. Food Allergy Testing—IgE Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58 Prick Skin Test (PST)—IgE Serum IgE–(CAP–System FEIA) Quantitative measurement of food specific IgE Double Blind Placebo Controlled Food Challenge- Considered “Gold Standard” for FA diagnosis

11. Food Allergy Guidelines Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58 Serum IgE or PST may be used to identify foods that potentially provoke IgE-mediated food induced allergic reactions, but alone, these tests are not diagnostic. The expert panel does not recommend routine screening for food allergy.

12. Severity of Food Allergy Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58 The severity of a potential allergic reaction can not be predicted by IgE level or by size of a PST.

13. Dietary Manipulation as a Diagnostic Tool Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58 • The food allergy guidelines suggests elimination of one or few specific foods to make the diagnosis of FA, especially in non-IgE medicated food allergic disorders. • Useful when chronic symptoms or delayed symptoms make determining the cause difficult. • Removal of the suspected allergen with anticipated significant improvement or remission of symptoms.

14. Disorders Not Proven to be Related to Food Allergy Migraines Behavioral / Developmental disorders Arthritis Seizures Inflammatory bowel disease

15. UnprovenDiagnosticTests • Basophil histamine release/activation • Lymphocyte stimulation • Facial thermography • Gastric juice analysis • Endoscopic allergen provocation • Hair analysis • Applied kinesiology • Provocation neutralization • Allergen-specific IgG4 • Cytotoxicity assays • Electrodermal test (Vega) • Mediator Release assay (LEAP) Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010

16. Education and Training: Avoidance Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the united states: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126 (6): S1-58 The food allergy guidelines suggest providing education and training to all individuals with documented food allergy on how to recognize labeling of food allergens on food labels.

17. Avoidance • Avoidance sheets • Reading food labels • Understanding cross contact in manufacturing • Understanding cross contact in restaurant, food service or home kitchen • Minor ingredients www.cofargroup.org and www.foodallergy.org

18. Label Reading Read the entire product label each and every time an item is purchased.

19. Label ReadingFood Allergen Labeling Consumer Protection Act (FALCPA) Milk Egg Wheat Soy Peanut Tree nut* Fish* Crustacean shellfish* *Specific species must be listed "Food allergen labeling consumer protection act” www.cfsan.fda.gov

20. Incidental Ingredients A “major food allergen” may not be omitted from the product label even if it is only a minor ingredient. Allergens not considered “major” may remain unidentified on product labels.

21. Cross-Contact Cross contact occurs when safe foods come in contact with an allergen, causing the safe food to contain small amounts of unintentional allergenic ingredients.

22. Cross Contact • Precautionary labeling such as • May contain… • Manufactured in a facility… • Manufactured on shared equipment… • Voluntary and unregulated

23. The Amount of Allergen in Products Assessed 7/68 3/57 Hefle et al JACI 2007 2/51 % of products with detectable allergen Overall 7% of all products (n=179) with advisory statements tested contained detectable allergen residue. With permission, Scott Sicherer, MD

24. Risk Associated with Milk Advisory Statements Crotty JACI 2010 Overall milk was detected in 36% of products (n=147) with milk advisory statements Dark chocolate had the highest % with detectable milk in 82% of samples with milk advisory statements.

25. FoodAllergyGuidelines • NIAID guidelines suggest avoiding any product that has any advisory statement for your allergen. Boyce JA, Assa'ad A, Burks AW, et al. JACI 2010.

26. Label Reading Summary Read product labels each and every time an item is purchased. Look at the ingredient list and precautionary labels. Avoid products that have a precautionary statement for your allergens. May need to call manufacturers for additional product information.

27. Food Service Managers should conduct food allergy training and review of the food allergy management plan periodically to be sure that both new hires and existing employees are properly trained. Employees should understand how cross-contact can occur. The food service establishment should have at least one person on duty, ideally the manager, who can handle questions and special requests from students with food allergies.

28. Food Service Other staff members should know who the food allergy manager is and should always direct questions about food allergies to that person. A cafeteria should be able to supply, upon request, a list of ingredients for a menu item. If a mistake occurs with an item prepared for a student with a food allergy, the only acceptable way to correct the situation is to have the kitchen staff discard the incorrect item and remake it. If a student is having an allergic reaction, call 911 and get medical help immediately!

29. Cross-Contact in the Cafeteria Consider anything used for more than one food and not cleaned completely! • Utensils, dishes • Cutting boards • Grinders, blenders • Hands • Gloves (no latex) • Processors • Salad bars • Pots, pans • Fryers • Grills • etc., etc...

30. Cross Contact • Problem • Allergen-free foods may come in contact with an allergen in storage, in the refrigerator or the cupboard. • Solution • Designate a separate shelf in the refrigerator and cupboard for allergen-free foods. This shelf should be above the shelf that may store foods with potential allergens. Consider using stickers to identify “safe” foods.

31. Cross Contact • Problem • A knife used to spread peanut butter may also be dipped in the jelly jar, tainting the jelly with peanut protein. • Solution • Keep a separate jelly jar for the students with allergies. Use clean knives in jelly first. • Problem • Preparing an allergen (chopping walnuts on a counter surface) and then a safe food (slicing tomatoes) without properly cleaning. • Solution • Prepare the allergen safe food first. Clean cooking equipment including the cooking area with hot soapy water.

32. Cross Contact • Problem • Plain French fries are fried in a deep fat fryer that was used to fry onion rings (containing milk, egg, and wheat). • Solution • Fry allergen-free foods separately in clean oil or in a dedicated fryer.

33. Cross Contact • Problem • Cafeteria lines and buffets may have greater risk of cross contact due to shared utensils and spills. • Solution • Keep the allergen-safe food completely separate to prevent cross contact.

34. To Avoid or Not to AvoidMinor ingredients and cross reactive proteins

35. To Avoid or Not to Avoid Crevel, Kerkhoff, Konig. Allergenicity of refined vegetable oils. Food and Chemical Toxicology. 2000;38:385-393. • A patient with corn allergy? • Corn oil or corn syrup? • A patient with soy allergy? • Soy oil or soy lecithin? • A patient with peanut allergy? • Peanut oil?

36. To Avoid or Not to Avoid Sicherer SH. Clinical implications of cross-reactive food allergens. JACI 2001;108:881-890 • A patient with sesame allergy? • Sesame oil? • A patient with egg allergy? • Egg white or egg yolk? • A patient with peanut allergy? • Tree nuts or other Legumes?

37. www.foodallergy.org Every student with a food allergy should have an Emergency Treatment plan signed by their MD.

38. It Takes a Team • Student/ Health and Wellness Center /Cafeteria/ Center personnel • Student informs Health and Wellness Center and the Cafeteria of the food allergy • Health and Wellness Center ensures the student has an Emergency Treatment plan signed by MD • Health and Wellness Center and Cafeteria communicate information about student’s allergy

39. It Takes a Team: Cafeteria Strict Avoidance – one bite can hurt Know ingredients/Know the student with allergies Read all labels – contact manufacturers Store ingredients to prevent cross contact Use clean utensils, cooking areas and cooking equipment May consider a designated area for prep of allergen-free foods. Prepare allergen free foods first,cover and remove from cooking area Serve separately – not from cafeteria line

40. It Takes a Team • Assure correct personnel are identified • Identify those trained in food prep for the students with allergies • Identify those trained to answer questions about ingredients and food prep methods • Identify those who will enact emergency action in the event of a reaction • Identify JC center environments that might pose a risk and create procedures to reduce risk • If a reaction occurs, activate emergency action promptly

41. 3 R’s of an Anaphylaxis Plan • Recognize the symptoms early • React quickly-provide appropriate medication, call 911 • Review what caused the reaction ***Every center should have a plan for managing food allergies

42. Treatment of Food Anaphylaxis Intramuscular epinephrine—EpiPen or Twinject Prompt administration is key tosurvivinganaphylaxis. Fatalities have resulted from adelay/failure to give epinephrine. Follow up in the ED or call 911 4-hour observation period

43. Nutrition Counseling Boyce et al. Guidelines for the diagnosis and management of foods allergy in the US. JACI 2010 Food Allergy Guidelines recommends all children with food allergy receive nutrition counseling and close growth monitoring.

44. Children with multiple food allergies or cow’s milk allergy are at increased risk of… Macronutrient/Micronutrient deficiencies or imbalance Shorter stature Failure to thrive Nutritional Rickets/kwashiorkor/marasmus Christie L, et al. J Am Diet Assoc. 2002;102:1648–1651. Henriksen C, et al. Acta Paediatr. 2000;89:272–278. Isolauri E, et al. J Pediatr. 1998;132:1004–1009.  Fox AT, et al. Pediatr Allergy Immunol. 2004;15:566–569.  Fortunato JE, et al. Clin Pediatr (Phila). 2008;47:496–499.  Flammarion et al. Pediatr Allergy Immunol. 2011; 22: 161-165.

45. Cow’s Milk Allergy • Foods to avoid: milk, butter, cheese, yogurt, custard, ice cream, puddings…as well as numerous manufactured products such as many margarines, breads, cookies, cakes, chewing gum, cold cuts, crackers, cereals, non-dairy products, processed and canned meats and many frozen and refrigerated soy products

46. Nutritional Contribution of CM Calcium Vitamin D Vitamin A Vitamin B12 Riboflavin Pantothenic acid Phosphorous Protein and fat

47. Comparison of CM Substitutes

48. Wheat Avoidance • Bread, cereal, pasta, crackers, cookies, cakes, condiments, marinades, cold cuts, soups, low-fat or non-fat products • 4 servings of enriched and whole grains provides 50% of the RDA for CHO, iron, thiamin, riboflavin and niacin for children>1 yr. and also a significant source of B6 and manganese.

49. Alternative Grains • Rice • Corn • Oat • Rye • Barley • Buckwheat • Amaranth • Quinoa • Millet

50. Cross-Reactive Grains • 20% of those with wheat allergy may be clinically reactive to another grain. *Use of alternative grains should be individualized and based on tolerance as determined by the patient history or by the allergist.