Adverse Reactions To Food

Learning objectives for Today

To understand there are many different
reasons for unpleasant reactions to food.
To know which foods may cause a food
intolerance and/or allergy.
To recognise the symptoms of food
intolerance and/or allergy.
To understand the severity of peanut allergies.
To recognise the seriousness of anaphylaxis.
To understand the terms oral allergy
syndrome.
To understand the cause and effects of
lactose intolerance and coeliac disease.
 Adverse reactions to food
TOXIC Nontoxic

Non immune
Immune-mediated
mediated

Allergy Intolerance

Non IgE mediated Enzymatic

IgE mediated Pharmacologic
Undefined

Adverse reaction to food: Position

paper. Allergy 1995; 50:623-635
Food intolerance

Most people can eat foods without

any problems although they may
have different likes or dislikes that
influence what they choose.

However, some people react to

certain foods and eating them
may cause uncomfortable
symptoms or, in rare cases, a
severe illness.
Symptoms of Food Intolerance

Nausea
Stomach Pain
Gas, cramps, bloating
Vomiting
Heartburn
Diarrhoea
Headaches
Irritability or Nervousness
Lactose intolerance

One type of food intolerance is caused by

insufficiency of an enzyme in the lower
intestine that is needed to digest a
component of food.

The most common example of this is

lactose intolerance where sufferers have
low levels of the enzyme needed to
digest lactose, the sugar found in milk.
Lactase breaks down the lactose so that
it can be absorbed.
 Lactase Deficiency
Lactose that is not hydrolyzed into galactose and
glucose remains in the gut and acts to osmotically
draw water into the intestines.
Bacteria ferment the undigested lactose, creating
lactic acid, other organic acids, CO2 and hydrogen
gas.
Lactose intolerance is common in some ethnic
groups, particularly where adults do not traditionally
drink milk.
People with lactose intolerance can usually drink
small amounts of milk, yoghurt and eat cheese
without problems.
If symptoms are severe, alternative sources of
calcium must be eaten.
 Symptoms of Lactose Intolerance

Watery loose stool (diarrhoea)

Gas, cramps
Abdominal bloating and pressure
Cramping pain in abdomen
Flatulence
Vomiting
Poor weight gain

8
Lactose intolerance

Children are usually born with sufficient lactase but in some

parts of the world, levels fall rapidly after childhood.

Lactose intolerance is typically seen in adults and is more

common in people of African and Asian descent. Less
common in Caucasians.

In the UK, US, Australia, only 5% of the population is

affected, to varying degrees.
 Lactose Intolerance
Breath hydrogen test

Individuals
are
administered
lactose, after
which expired
air samples
are collected
for 3 hours to
assess
hydrogen gas
concentrations

A rise in breath hydrogen concentration greater than 20 parts per million over the baseline after
lactose ingestion suggests lactase deficiency
 Management of Lactose Intolerance

Only the milk sugar, lactose, needs to be avoided

This is not a milk allergy:
Milk proteins are tolerated
Lactose occurs in the whey (liquid) fraction of milk
Milk products free from lactose and free from whey
are safe
These foods include:
Milk treated with lactase
Hard cheeses (whey is removed; casein remains and is
fermented to form cheese)
Many people tolerate yogurt, where lactose is broken down by
bacterial enzymes
14 Oral Lactase supplements can help.
 What is an Allergy?

Allergy - immune system causing a reaction against normally

harmless substances-.
Such substances are generally referred to as "allergens".
The reaction creates an inflammation which, can lead to symptoms
such as
hay fever, eczema, asthma and other allergic conditions

.
Tell the difference?

INTOLERANCE
Intolerance is dose related
Found through trial and error (food diary)
Elimination diet and reintroduce foods one at a time

ALLERGY
Allergies can be triggered by even small amounts
occur every time food consumed
Advised to avoid offending foods completely
 Pollen

Dendri+c
cell
Allergen

Mucous
Membrane

T-cell Receptor
IgM
T-cell
epitope
MCHII
Dendri+c Naive
cell T-cell CD80 or
IL-4 CD86
CD28 Naive
B-cell
Jagged Notch

T2H CD40
CD40L
IL-4
Matura+on and
IL-13 Class switching
Mast cell IgE recombina+on

Plasma
cell

IgE Produc+on
Exposure

Genetic
Predisposition

Sensitization

Re-exposure

Symptoms
 PLANT ALLERGEN SOURCES

POLLEN
Grasses
Weeds
Trees

FOOD
Soybean,
Peanuts,
Wheat
Tree nuts
Allergies appear to be increasing in
prevalence

Allergies, including food allergies appear to be

increasing. The reason for the increase is
unclear but may be due to a number of causes
ranging from children living in cleaner
environments (the hygiene hypothesis) to better
diagnoses.
Allergy skin prick testing
What is Asthma ?
Chronic inflammatory disorder of the airway, making
breathing difficult. It is an airway inflammation
disorder. The level of airway responsiveness is due
to the exacerbating stimuli.
Allergens:
Dust mites (faeces)
Animals: Cats
Grass pollen
Food Allergy

Defined as adverse immunological

(hypersensitivity ) response and as such it is not
a single disease.
 Food Allergies

Most common foods responsible for

90% of all allergic reactions:
Reactions to peanut,
Cows milk tree nuts and shellfish
Eggs life long problem
Peanuts
usually more severe than
Wheat
Soy
other food allergies
Fish
Shellfish
Tree Nuts
Foods more frequently implicated in food allergy

Children Adults
Cows milk Fruits
Egg Peanuts
Fish Tree nuts
Peanut Fish
Fruits Shellfish
Legumes
Wheat
 Food Allergies

Food allergens are those parts of

foods that cause allergic reactions-
usually proteins

All foods come from either a plant or

animal source
Major food allergens
Cow's milk:
Caseins (, ,), -lactoalbumin, -lactoglobulin, serum albumin
Chicken egg:
Ovomucoid, ovalbumin, ovotransferrin
Peanut:
Vicillin, conglutin, glycinin
Soybean:
Glycinin, profilin, trypsin inhibitor
Shrimp:
Tropomyosin
Lipid transfer proteins (LTPs):
Apple, apricot, peach, plum, corn
Food Allergens- Properties
What are rules of allergenicity?
Physico-chemical properties-
Usually water soluble glycoproteins that are stable at low
pH.
MW >10,000
Stability to digestion, proteolysis,hydrolysis,heat and
changes in pH.
Cooking can destroy allergenicity of certain foods - Eggs.

Conversely heating can increase allergenicity-peanuts.

Food Allergies

Sulfites
Used to prevent certain foods from browning,
such as light-colored fruits, dried fruits and
vegetables
For 5-10% of people with asthma may be
susceptible to react to sulfites
Symptoms: wheezing, diarrhea, stomach
ache, hives or swelling
 Prevalence of food allergy

Precise prevalence is unknown, but

estimates are:
Adults: 1.4% - 2.4%
Children < 3 years: ~ 6%
Allergic dermatitis (mild/severe): ~35%
Asthmatic children: 6 - 8%
Prevalence depends on: Genetic factors,
age, dietary habits, geography and
diagnostic procedures
Adapted from Sampson HA. Adverse Reactions to foods. Allergy
Principles and Practice. 2003
 The Allergic Reaction
An allergic reaction to food can take place within a few minutes to hours.

outh
g i n M Hives - Eczema Diarrhea
Itchin

BP may d
rop Vomitting

htn ess
Throat tig
Breathing Difficulty c t i c Shock
nap h y l a
A
IgE dependent Food Allergy

Affect one or more target organs

Skin (urticaria, angio-oedema)
Respiratory tract (rhinitis, asthma)
Gastrointestinal tract (Pain, diarrhoea)
Cardiovascular system (anaphylactic
shock)
Cutaneous food hypersensitivities
Acute Urticaria* and Angioedema**:
The most common symptoms of food allergic reactions.
The exact prevalence of these reactions is unknown.
Acute urticaria due to contact with food is also common.
Chronic Urticaria:
Food allergy is an infrequent cause of chronic urticaria and angioedema.

* commonly known as hives-look like mosquito bites

** swelling of tongue and throat
 What does Anaphylaxis Mean?
Severe potentially fatal systemic
allergy reaction
Anaphylaxis is an overall allergic reaction
that causes:
Swelling of the airway
Difficulty breathing
Throat tightness
Sense of doom
Drop in blood pressure
 Avoidance Anaphylactic Strategies

AVOIDANCE of specific allergen is key to

preventing anaphylaxis
Food avoidance
Threshold Doses of Food Allergens

Taylor et al. Journal of Allergy and Clinical

Immunology 2002;109:24-30.
FOOD DOSE of PROTEIN
Peanut 0.2-125 mg
Egg 0.1-200 mg
Milk 0.6-180 mg
Mustard 0.3 mg
Fish 5mg-6 gm (Food)
Threshold Doses of Peanut Allergens

26 subjects.
Prospective double blind challenge with increasing doses of
peanut protein, 30 g to 1 gm.
Subjective symptoms of in all 26.
Dose: 100 g to 1 gm.
Objective response in 6. No change in FEV1 or BP.
Lip swelling in 3 Dose 0.1 to 10 mg
Laryngeal edema in 2. Dose 0.3-1 mg
Vomiting in 2 Dose 1 10 mg

Wensing et al. The distribution of individual threshold doses eliciting allergic reactions in a population
with peanut allergy. Journal of Allergy and Clinical Immunology 2002;110:915-20
Food Allergy

Food Allergy
Milk allergy sufferers need to know this means milk!

What does this mean?

Labeling
Oral allergy syndrome

In oral allergy syndrome, immune system

treats proteins similar to those in pollen that
are sometimes found in fruits or vegetables
the same way. That's called cross-reactivity.

Grass Pollen Allergy: May react to Celery,

Tomato, Melons

Latex Rubber Allergy: May react to Banana,

Avocados, Kiwifruit, Papaya
The celiac diet
 Gluten

Gluten is a protein that gives dough elas+city which

allows it to rise without collapsing while trapping the
CO2
Exists within wheat, rye and barley.
Also in wheat deriva+ves: bulgar, couscous, seitan,
semolina, tri+cale, spelt, einkorn, emmer and anything
with wheat in the +tle (except buckwheat).
 Celiac disease

Celiac disease, or gluten-sensitive intestinal

disorder, is a malabsorption syndrome occurring
in sensitive individuals upon the consumption of
wheat, rye, barley, triticale and spelt.
The consumption of wheat or other offending
grains or products made from these grains elicits
inflammatory damage to the absorptive epithelial
cells in the small intestine.
 Normal intestinal biopsy

Small intestinal biopsy in a patient with active

celiac disease

Source:NEJM
 Celiac disease

The loss of absorptive function along with the

ongoing inflammatory process results in a severe
malabsorption syndrome characterized by diarrhea,
bloating, weight loss, anemia, bone pain, chronic
fatigue, weakness, muscle cramps, and, in children,
failure to gain weight and growth retardation.
 Clinical features in adults

Lethargy Tired all the time

Anaemia (Fe, folate, B12 and mixed)
Abdominal pain
Non-specific abdominal symptoms
Diarrhoea
Weight loss
Osteoporosis
Sub-fertility
Diagnosis

1st: Physical exam and blood tes+ng

2nd: Duodenal biopsy
3rd: Implement gluten-free diet

hXp://www.csaceliacs.org/celiac_diagnosis.php
Treatment

Only treatment for celiac

disease is a gluten-free
diet (GFD)
Strict, lifelong diet
Avoid:
Wheat
Rye
Barley

55
Treatment of coeliac disease

Gluten-free diet
Avoidance of wheat, rye and barley
Dietician
Codex Alimentarius
Coeliac societies handbook
The Latest Fad
A new diet trend
Gluten only harmful to those with CD
No current evidence to back up gluten-free diet health
claims
Wheat our for+ca+on: B1, B2, B3 and Iron