Food Allergy – Indian Scenario

1. Food Allergy – Indian Scenario Dr. Ashok Gupta Asso. Prof. of Pediatrics, SMS Medical College, Jaipur Deputy Executive Director, International Society of Tropical Pediatrics Executive, International Pediatric Academic Leaders Association Medical Advisor, Food Allergy and Anaphylaxis Network, USA Member, EAACI Committee on Patient Group for Food Allergy

2. Epidemiology of Diseases in India

3. Continued… No registry of Food Allergy Patients No Medical college has a degree course in Allergy Demographic projections predict 22% of the total population suffer from some allergy (250 million)

4. Case Avinash – 8 year, Male, h/o Peanut Allergy visiting from USA Consumes packaged food with inadequate information, develops anaphylaxis July 6, 2010, Union Minister of Health, GOI accepted Food Allergy as a serious health problem

5. Case Anil – 1 yr. Male • Milk Ingestion induces – flushing, swelling, breathing difficulty • Milk anaphylaxis

6. Case Shrichand – 5 yrs. Male • Repeated papular urticaria • Partial response to antihistamines • Allergy test – wheat allergy • Improved on wheat withdrawal

7. Case Vicky – 5 yrs. male • Chronic Diarrhea • Failure to thrive • Rickets • Multiple nutritional deficiencies • Celiac Disease

8. Adverse Food Reactions may be mistaken for allergy Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning Caffeine Alcohol Histamine Non-immunologic Toxic / Pharmacologic Non-Toxic / Intolerance • Lactase deficiency • Galactosemia • Pancreatic insufficiency • Gallbladder / liver disease • Hiatal hernia • Gustatory rhinitis • Anorexia nervosa • Idiosyncratic Adapted from Sicherer S, Sampson H. J Allergy Clin Immunol 2006;117:S470-475.

9. Adverse Food Reactions Systemic (Anaphylaxis) Oral Allergy Syndrome Immediate gastrointestinal allergy Asthma/rhinitis Urticaria Morbilliform rashes and flushing Contact urticaria Immunologic IgE-Mediated (most common) Non-IgE Mediated Cell-Mediated • Celiac disease • Protein-Induced Enterocolitis • Protein-Induced Enteropathy • Eosinophilic proctitis • Dermatitis herpetiformis • Contact dermatitis • Eosinophilic esophagitis • Eosinophilic gastritis • Eosinophilic gastroenteritis • Atopic dermatitis

10. Natural history of food allergy Generally - reproducible reaction: same person, same food, same, similar or related symptoms May progress from dermatitis or hives to vomiting & wheeze to Asthma and Anaphylaxis ~ 85% of individuals with allergies to cows milk, egg, wheat, soy become tolerant by 3 yrs of age Allergy to peanut, nuts, seafood is typically permanent 10

11. Allergens Common in India Any food can be allergenic Patterns of common allergens differ across regions and cultures Dairy, eggs, peanuts, tree nuts such as walnuts, almonds and cashews, fish, shellfish, soya, wheat, seasame top the list Incidence of allergies to milk, eggs and wheat less frequent then in the West Dals (Pulses) such as chickpeas more common allergy to rice has been reported

12. Allergy distribution Evenly distributed More in urban and semi urban areas as compared to rural areas Changing food pattern moving away from Traditional Dal, Rice, Vegetables to Fast Food, Ice cream, Chocolate additionally increased Houses have Carpets & Pet

13. Foodallergy Non-allergicfoodhypersensitivity IgE-mediated food allergy Non IgE-mediated food allergy Foodhypersensitivity Food hypersensitivity • Non-allergic-foodhypersensitivity • Enzymatic- lactose intolerance • Pharmacological • - biogenic aminese.g. histamine, tyramine • Food hypersensitivity • Food allergy • IgE-mediated allergy • Non-IgE- mediatede.g. celiac disease

14. Allergens from a single site No. of Tests- 66778 (2008 & 2009)

15. IgE mediated Food Allergens in patients with Asthma and allergic rhinitis. No. of patients- 1860 patient.

16. Studies on large scale surveys • Moshe Ben-Shoshan etal, Montreal, Canada – Population based study on Peanut, Tree nut, Fish, Shellfish, and Sesame allergy prevelance in canada • EuroPrevall • Gerez etal – Singapore Medical Journal

17. Definition of Food Allergy • Perceived food allergy – Self reported • Probable Food Allergy – Self reporting / Physician confirmed • Confirmed Food Allergy – Convincing clinical history of IgE reaction / positive SPT

18. Methodology • Telephone surveys • Trained Interviewer • Respondents 18 years older with no language mental hearing barriers • Questionnaire • Statistical Analysis

19. No. of New Celiac cases

21. Distribution of Celiac Diseases Cases 24% 76%

23. Compliance

25. Rising incidence of symptomatic celiac patients Need for appropriate education of parents, children & medical personal Need for strategies of prevention - Delayed introduction of gluten - Breast Feeding High index of suspicious in children with Typical presentations & in asymptomatic IDA, Hypothyroid, 1st degree relicts. IDD & Hypothyroid not responding to treatment need to be screamed. Regulatory mechanism for labeling & assessing of gluten free products.

26. KAP Anaphylaxis Medical College Faculty & Residents - 32% General Practioner - 9.2% Food Allergy diagnosis Medical College Faculty & Residents - 44 % General Practioners - 11.2%

27. Conclusions Food allergy on the rise Need for establishing a national registry Urgent need to educate medical personnel Social & Psychological cost to the patient and the family Food labeling Scientific support on preventing food allergy & making food safe Quality control of marketed foods

28. Thanks