ALLERGIES AND FOOD INTOLERANCES

1. ALLERGIES ANDFOOD INTOLERANCES

2. DEFINITIONS ALLERGEN – a foreign protein or antigen that induces excess production of certain immune system antibodies. Subsequent exposure leads to the allergic response. Can cause a rapid increase in heart rate and difficulty in breathing. House dust mites, pets, pollen insects, moulds, foods and medicines. Allergy occurs when a person’s immune system reacts to substances in the environment that are harmless for most people Food Allergy: occur in ATOPIC people – those born with overactive immune systems that produce IgE antibodies to substances in their environment or diet which would normally be harmless. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

3. FOOD INTOLERANCE – an adverse reaction that does not provoke an allergic reaction or the immune system, but the sensory nerves that trigger a reaction. FOOD SENSITIVITY – a mild reaction to a substance that may be expressed as a light rash or itching See www.allergy.org.au and www.allegy.net.au Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

4. Overview Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

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7. Symptoms and mechanisms • Allergic reactions to food are quite common and occur more frequently in females than in males. • Food allergies occur most frequently during infancy and young adulthood. Experts estimate that up to about 1% to 2% of adults and up to about 4% to 8% of children are allergic to certain foods. • Occurs in around 1 in 20 children and in about 1 in 100 adults. • Symptoms can include • Nose and/or eyes hay fever, allergic rhinitis/conjuctivitis • Skin – eczema, hives • Lungs - asthma Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

8. Allergic reactions vary not only in the body system affected but also in their duration, ranging from seconds to a few days. A generalised, all-systems reaction is called anaphylactic shock. This severe allergic response results in lowered blood pressure and respiratory and GI tract distress. It can be fatal. Although any food can trigger anaphylactic shock, the moist common culprits are peanuts, tree nuts (walnuts, pecans etc), shellfish, milk, eggs, soybeans, wheat and fish. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

9. Any reaction that is milder than these distinct allergic ones is referred to as a food sensitivity. • Three types of reactions may occur after ingestion of problem foods by susceptible people: • Classic – itching, reddening of the skin, asthma, swelling, choking, and a runny nose • GI Tract – nausea, vomiting, diarrhoea, intestinal gas, bloating pain, constipation, and indigestion • General – headache, skin reaction, tension and fatigue, tremors and psychological problems Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

10. Halkin,S. 2004, `Prevention of allergic disease in childhood: clinical and epidemiological aspects of primary and secondary allergy prevention’, Pediatric, Allergy and Immunology, vol.15, no.suupl 16, pp.4-5, 9-32) The development and expression of atopic diseases depends on a complex interaction between genetic factors, environmental exposure to allergens and non-specific adjuvant factors, such as tobacco smoke, air pollution and infections. Preventive measures may include both exposure to allergens and adjuvant risk/protective factors and pharmacological treatment. The combination of atopic heredity and elevated cord blood IgE resulted in the best predictive discrimination as regards development of allergic disease. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

11. In symptomatic children allergen-specific treatment may influence both the symptoms and the prognosis. • Allergen avoidance can reduce the need for pharmacological treatment, • SIT may have the potential for preventing the development of asthma in children with allergic rhinoconjunctivitis. • It may be possible to interfere with the natural course of allergic diseases. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

12. (Lance,F., Micheau,P., Marchac,V., Scheinmann,P. 2003, `Food allergy and asthma in children’, Revue de Pneumologie CLinique, vol.59, no.2 pt 1, pp. 109-13) The links between food allergy and asthma are becoming more clear. The association of food allergy and asthma in the same child is unusual (less than 10% in atopic subjects). This association is however a sign of gravity leading to more severe manifestations of food allergy in asthmatic children. Compared with the non-asthmatic child, the asthmatic child has a 14-fold higher risk of developing a severe allergic reaction to the ingestion of food. The most commonly cited foods are fruits with a rind, cow's milk and, of course, nuts. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

13. Coeliac Disease Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

14. An Autoimmune Disease The body makes antibodies against the cells of the SI, in response to gluten ‘contaminating’ the cells of the small intestine. Results in the villi become inflamed and flattened which results in decreased ability to digest foods and absorb nutrients from the food. The resulting villi atrophy can lead to nutrition deficiencies for all nutrients, but of particular concern is Iron, Calcium, Magnesium, protein. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

15. Symptoms or can be Asymptomatic Fatigue, weakness and lethargy Anaemia Flatulence and abdominal distension Diarrhoea and/or Constipation Cramping and bloating Nausea and vomiting Weight loss/gain Less common but possible: Easy bruising Recurrent mouth ulcers and/or swelling of mouth or tongue Miscarriage and infertility Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

16. Low Ca, vitamin and other mineral deficiencies Skin rashes including dermatitis herpetiformis Dental defects Altered mental alertness Bone and joint pains In children As above, and Steatorrhea Poor weight gain Weight loss in older children, Delayed growth or delayed puberty Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

17. Possible Co-Morbidities • Hair loss • Dental enamel defects • Infertility and recurrent miscarriage • Lethargy • Mouth ulcers • Osteoporosis • Reproductive issues • Changes to gut integrity that may or may not resolve with gluten avoidance. Other autoimmune diseases • A-1 atropic gastritis • Addison disease • Colitis • Congenital heart defects • Dermatitis herpetiformis • Don’s syndrome • Hypo-splenia • IgA nephropathy • Liver enzyme disturbance Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

18. Neurological incl neuropathies, ataxia, memory impairment, migraines, epilepsy or muscular stiffness • Primary biliaary cirrhosis • Psoriasis • Sarcoidosis • Serum IgA deficiency • Sjorgren syndrome • Thyroid hypo or hyper • Turner syndrome • type 1 diabetes • Williams syndrome • Small but possible Ca risk with untreated celiac disease Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

19. Food Intolerances Food intolerances are adverse reactions to chemicals in food that do not involves allergic mechanisms. It is nerve/sensory reaction that causes the symptom expression. Generally, larger amounts of the offending food are required to produce symptoms of intolerance than to trigger allergic symptoms. Symptoms are person specific, and can change with different chemicals. Just because it is natural, doesn’t Mean Your body will like it. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

20. Common symptoms are • Recurrent hives and swellings. • Stomach and bowel irritation • Headaches. • Some people have flue like • aches & Pains, • Unusually tired, run down or moody • Children can be irritable, restless, with aggravated behaviour such as ADHD. • Babies colicky irritable behaviour, reflux, loose stools, eczema and or nappy rashes. • Symptoms can depend on a number of factors include predisposition to sensitivity, dose and frequency of consuming those chemicals. Because many foods naturally contain a mix of irritants, than the type of food can push an individual over the edge. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

21. Additive Effect Foods containing chemicals/Chemical Load Threshold/ Symptoms Time/dose Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

22. The additive effect of chemicals over a period of time, either single or mixed can over a period of time push a person over their threshold, and symptoms occur. Because of the mixed chemicals in food, and the accumulative effect they can have in the body, it is important to determine which chemical it is and the individual’s tolerance level to it. The tolerance level can also change with stress, circumstances and avoidance of offending foods for a long period of time. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

23. Common causes • Certain foods such as red wine, tomatoes, pineapples that cause physiological effects such as a change in blood pressure • Synthetic compounds such as sulphates, food colouring agents and MSG • A reaction to Tartrazine, a food colouring additive • Food contaminants including antibiotics, chemicals or even insect parts Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

24. Tyramine, a derivative of the amino acid tyrosine, is commonly found in aged foods such as cheeses and red wine, can cause high blood pressure in people taking MAOI’s for depression or mental disorders • Toxic contaminants such as salmonella bacteria or clostridium botulinum or other food borne microbes • Digestive enzyme deficiency e.g. lactase Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

25. Common Foods It is very possible to be sensitive to more than one chemical And include: • Natural food chemicals salicylates, amines, glutamate, • Food additives. • Considering all plants and animals must protect themselves from a mirage of insects, moulds, yeasts it is very possible for a food to contain a mix of these naturally occurring chemicals at any one time. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

26. Salicylates plant chemicals naturally found in • many fruits & vegetables, • nuts, • herbs and spices, • Jams & honey, • yeast extracts, • tea, coffee, juices beer and wine. • Natural flavourings used in foods, • drinks • and liquid medications. • scents in perfumes, • toiletries, • cleaning products, washing powders and • essential oils. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

27. Amines • From protein breakdown • Levels increase in protein foods as they age or mature – meats, fish and cheese • and fruits as they ripen • Bananas, tomato, avocado, pawpaw, olives High levels are in • sauces, fruit juices, chocolate • Flavoured spreads – nuts and seed pastes & jams • Fermented products beer, wine and yeast extracts. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

28. Other Food Chemicals Glutamate • An AA of protein found naturally in most foods. • In free form it enhances the flavour of food. • Cheese, tomato, mushrooms, stock cubes, soy sauce, meat & yeast extracts. Lactose • Sugar in milk products. • If reactive to chocolate, hard cheese, and cakes. It is likely not lactose, but other chemicals in these foods. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

29. Fructose, Fructans and Prebiotics Found if fruits and normally able to be absorbed across the SI. Illness, SI damage, antibiotics and stress can reduce the digestion of fructose in the SI and alter the bacterial balance of the LI. Gut bacteria ferment the fructose and non digestible fibres causing swelling and irritation to the gut. This can also cause gastro like reactions causing discomfort, and flatulence. Of particular interest for clients with IBS Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

30. Food Additives Used to enhance flavour, appearance, maintain freshness and increase shelf life of foods. The body can not determine if it is natural or artificial in processed foods as they are chemically similar or identical. People sensitive to natural chemicals, are usually sensitive to one or more common additives of preservatives, artificial colour & flavourings. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

31. Sulphites, which are added to food and beverages as antioxidants, cause flushing, spasm of the airways, and a loss of blood pressure in susceptible people. Wine, dehydrated potatoes. Dried fruits, gravy, soup mixes, and restaurant salad greens commonly contain sulphites. • A reaction to MSG may include an increase in blood pressure, numbness, sweating, vomiting, headaches and facial pressure. MSG is commonly found in Chinese foods and many processed foods e.g. soups Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

32. Tyramine, a derivative of the amino acid tyrosine, is commonly found in “aged” foods, such as cheeses and red wines. This natural food constituent can cause high blood pressure in people taking monoamine-oxidase inhibitor medications, which may be prescribed for mental depression. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

33. Organic Foods? By not using pesticides and other chemicals to ward of pests it forces the plant to increase its own production of pest control chemicals, in particular salicalytes. For people who are sensitive, this is a point to be aware of. They might be getting ‘better’ quality of nutrient richness, with an increased natural chemical load. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

34. Diagnosis Pathway 2- 6 Weeks  5 well days 6-8 weeks Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

35. Irritable Bowel Syndrome Irritable bowel syndrome (IBS) & chronic inflammatory bowel disease (IBD) is a difficult but an important challenge to recognize and treat. Chronic inflammation in IBD, IBS symptoms occur with increased frequency and severity, secondary to increased hypersensitivity to foods and beverages that stimulate the gastrointestinal tract. The adverse effects of many foods and beverages are amount dependent and can be delayed, additive, and cumulative. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

36. The specific types of foods and beverages that can induce IBS symptoms include • milk and milk containing products – lactose and proteins • caffeine containing products • alcoholic beverages • Fruits and fruit juices • Spices and seasonings • diet beverages, diet foods, diet candies, diet gum • fast foods, fried foods and fatty foods • Condiments, gravies, spaghetti sauce, • multigrain breads, sourdough breads, bagels • Salads and salad dressings • Vegetables, beans, high fibre • red meats, stews, nuts, popcorn • cookies, crackers, pretzels, cakes, and pies. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

37. The types of foods and beverages that are better tolerated include • water • Rice, plain pasta or noodles • baked or boiled potatoes • white breads • plain fish, chicken, turkey, or ham • eggs • dry cereals • soy or rice based products • peas • Applesauce, cantaloupe, watermelon, fruit cocktail • margarine • Jams, jellies, and peanut butter. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

38. Possible Causes Immune system imbalance Use of antibiotics causing dysbiosis Western eating plan that disrupts the chemical balance of the gut Low stomach acid – reduced digestion of proteins and nutrient activation: minerals and B12 Medications Irritants in foods Stress, hormone imbalance Slow transit time Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

39. FODMAPs • Fermentable • Oligosaccharides - Fructans, Galacto-oligosaccharides (GOS) • Disaccharides - Lactose • Monosaccharide Fructose in excess of glucose • And • Polyols sorbitol manitol These are all CHO based foods with sorbitol and manitol being sugar alcohols. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

40. Mechanism of FODMAPs Fodmap compounds are poorly absorbed in the small intestine and enter the large intestine The bacteria digests and ferments these CHO and Sugar alcohols producing gas and other essential acids. It also causes osmolarity changes, which draws water into the colon. This and the increased gas, leads to dissention of the colon wall, irritating the sensory nerves and increases motility – diarrhoea and faecal urgency. Pain, bloating, distension, wind, constipation +/- diarrhoea can occur. Via the sensory Hypothalamus-Pituitary-Adrenal Axis, triggers secondary responses which can perpetuate the problem Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

41. Now What??? Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

42. Determine Which Tx Pathway!! Considering the overlapping presentation of symptoms, and foods it is vital to determine which is the pathway of the symptoms the body is following. If this is inaccurate than the condition may not resolve easily or at all. The condition may not resolve even if you and client have correctly determined the pathway and treatment modality if the person is hypersensitive, or if they continue to consume foods that are an irritant to them. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

43. Shared Symptoms, Different Reaction IgE T Cell Mediated Non-Immunological Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

44. Assessment strategy As part of a complete history taking, you need to target: • History targets Includes but not limited to • description of symptoms, • time between food ingestion and onset of symptoms, • duration of symptoms, • most recent allergic episode, • quantity of food required to produce reaction, • suspected foods, • and allergic diseases in other family members • History of other autoimmune diseases. • Complete Family Sensitivity History & Total Body Load Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

45. Physical • Physical examination • Look for signs of an allergic reaction (rash, itching, intestinal bloating, sinusitis, etc) • Functional bowel symptoms • Bloating, pain, sensitivities. • Urgency of elimination • Irritable bowel like symptoms. • Smell, texture color etc of motions • BMI • Weight change and %; malnutrition scale • Growth charts for children Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

46. Patient presents with symptoms and food history Other Diagnosis Assess Alarm Features Appropriate Treatment Coeliac Testing and other Testing Functional Bowel Disorder RPAH Elimination Diet no yes Breath hydrogen & methane with fructose and lactose to assess absorptive capacity Restriction of lactose if lactose malabsorption present Complete FODMAP restriction Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

47. Pathology Tests Allergy • RAST Test to identify elevated IgE antibodies. Does not conclude allergy . • Allergy - testing under supervised conditions if at risk of anaphylactic reaction. Coeliac testing • If currently eating gluten, request pathology for Coeliac disease either Ab anti-transmutase or Gene test - HLA DQ2/DQ8 tissue typing for family risk. Small bowel biopsy • If not eating gluten, encourage to do so and follow up with tests. • If –ve, consider intolerance and follow elimination diet or if bowel symptoms are predominant consider FODMAP. • Food challenge • Add back small amounts of excluded foods one at a time, as long as anaphylactic shock is not a possible consequence Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

48. Other tests of value include Liver function, Serum Ferritin, Ca2+, B12, Folate, albumin. BGL; GTT; immune function Hydrogen, methane breath testing. CAM tests Functional liver test Stool anaylsis Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

49. Assessment Phase Based on the information gleaned, pathology collected and interpreted a change in eating plan will result. Which one will be determined by the diagnosis or in some cases no diagnosis. Be sure all possible pathological causes are cleared before embarking on a massive treatment plan. Undiagnosed, serious conditions can manifest if left untreated. If the client chooses not to follow investigative processes, then consider referring them on, signing a waiver form, and be sure you have discussed the possible outcomes of not following this pathway first. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.

50. Treatment of food allergies Refer back to the allergy clinic or under medical supervision to complete tests. Once allergens are identified, ensure the client is meeting nutritional needs while Avoiding known allergen/s Educate the client how to read labels and the common names for the allergen so they can avoid accidental exposure. Be aware of: Allergens can cross the placenta during pregnancy and can be secreted in the breast milk 80% of children with food allergies outgrow them before 3 years of age. Written by leah Marmulla for use by AoCH 2011. use without written permission prohibited.