1. Peggy White, MS, RD, LD

2. FOOD ALLERGY VS FOOD INTOLERANCE Food Allergy – Allergic response when the immune system reacts to a food (usually the protein) or “foreign material” by producing inflammatory mediators such as histamine, prostaglandins, and leukotrienes to destroy the “detected” threat. The symptoms are caused by the person’s unique reaction to the food, not the food itself. Food Intolerance – refers to a reaction that does not involve the immune system. It is caused by a problem in the way the body processes the food or food additive. Two examples are lactose intolerance and celiac disease.

3. FOOD ALLERGIES Consume food  Food is digested and absorbed  Immune system processes and responds  Inflammatory mediations are released  allergy symptoms: respiratory tract, digestive tract, skin reactions, and system anaphylaxis. Can also occur when coming in contact with the food. Allergy is an inherited tendency and research indicates that certain genes may be responsible. Children often outgrow food allergies by age 5. Most likely to outgrow milk, egg, wheat and soy. Most likely to persist are peanuts, nuts, fish, and shellfish. Eosinophilic esophagitis now determined to be caused from an allergic response.

4. FOOD INTOLERANCE 1. Toxic reactions – food poisoning in response to a microbial toxin a. salmonella b. e coli 2. Metabolic dysfunction – enzyme dysfunction a. Lactase deficiency 3. Pharmacologic response – pharmacologically active agent. a. Mao inhibitors/tyramine

5. TOP ALLERGENIC FOODS Eight foods are responsible for 50% of allergic reactions. 1. Peanuts and peanut products * 2. Soy and soy products 3. Eggs and egg products * 4. Milk and milk products * 5. Tree nuts, such as pecans, almonds, walnuts * 6. Fish and fish products * 7. Shellfish * 8. Wheat and wheat products * * Most severe reactions and the most causes of anaphylaxis

6. FOOD ADDITIVES Lecithin – potential allergens are eggs, egg yolk, soybeans, and corn. Used as an antioxidant and emollient. Found in breakfast cereals, candy, chocolate, breads, rolls, and margarine. Starch – potential allergens are wheat, potatoes, rice, corn, beans, The plant source is usually not identified on the label. Used as a thickening agent. Found in thickened or creamed items. Hydrolyzed Vegetable Protein – potential allergens are soybeans, peanuts, wheat, corn. Soybeans are the usual source and it is used as a flavor enhancer and to add protein. Xanthan Gum – the product of fermentation of dextrose which is derived from corn syrup. Used as a thickener or stabilizer. Likely found in dairy products, salad dressings. Often replaces starch, sugar, and oil in low calorie products.

7. MILK ALLERGY AND LACTOSE INTOLERANCE MILK ALLERGY Milk allergens are proteins – casein, whey, and serum. Casein produces the highest number of reactions. More common in children than adults, 90% are developed in the first year of life. Children outgrow by 18 months to 2 years due to maturing of digestion and immune systems. Milk allergy can cause inflammation of the GI tract and lead to lactase deficiency.

8. Lactose Intolerance Lactose is milk sugar and lactose intolerance is caused by the lack of the enzyme lactase to breakdown the lactose to glucose and galatose. The lactose molecule is too large to pass through the cells lining the GI tract. Lactase deficiency is uncommon in infants and children. Most adults lose some degree of lactase activity after puberty. Certain ethic groups are more prone to lactose intolerance – Oriental races, African blacks, people of Middle Eastern decent, and those from the Mediterranean region have an 80% occurrence of lactose intolerance. Lactose can be found in medications.

9. MILK FREE DIET Foods to Avoid Milk, milk containing foods, yogurt, buttermilk, all cheeses, ice cream, ice milk, foods with milk solids such as margarine, butter, cream, foods or beverages with whey or casein. Hidden sources are deli meat slicers, some canned tunas, meats with casein as binders. Some medications contain whey. Lactose intolerance is easier to manage due to lactose free products. Lactaid milk, Lactaid powder, soy and almond milks.

10. EGG ALLERGY High risk of anaphylaxis due to many different protein in eggs. Persons with egg allergy must avoid eggs in any form. It can be useful to know which part of the egg you are allergic to, allergy to the white part of the egg most common. Egg Free Diet – Eggs are easy to omit when eaten whole, but eggs are contained in many products. Desserts such as ice cream, puddings, baked goods, pasta, salad dressings, meats with eggs as binders, mayonnaise, sauces such as hollandaise, bearnaise, quiche, and egg beaters. There are commercial egg substitutes on the market. Egg emulsifier is found in IV intralipids.

11. SOY ALLERGY Soy and soy products are legumes and are related to peanuts, but a person is usually allergic to only one member of the legume family. Forty three percent of babies that are allergic to cow’s milk also develop a soy allergy. Soy Free Diet – Tofu, soy milk, soy sauce, textured vegetable protein, miso. Soy is used as an emulsifier or stabilizer in baked goods, granola bars, some commercial soups, cold cuts, mixed bean soup, crackers, cereals, and infant formulas. If a person is highly allergic, need to also avoid soybean oil, sprays, and margarines.

12. PEANUT ALLERGY Peanut allergy is the most frequent cause of anaphylaxis, but in reality has caused very few deaths. Peanuts are botanically different from tree nuts and most people allergic to peanuts can eat other nuts. Watch out for “nut mixtures”, handles where nuts are sold, candies, ice cream. Peanut free diet – Peanuts, ready to eat cereal with nuts, granola, Chinese and Thai dishes, egg rolls, peanut butter, chili sauce, hot sauce, mole sauce, salad dressings, potato pancakes, glazes, and marinades. Must avoid peanut oil because could have traces of protein.

13. FISH AND SEAFOOD ALLERGY Salmon, tuna, and halibut are the most common kinds of fish that cause allergy. Cosmetics can contain fish gelatin that also cause allergy. Usually allergic to either fish or shellfish. Foods to avoid – Avoid fish, fish oils, Asian dishes, Caesar salad with anchovies, foods with fish gelatin; certain baked goods, candy bars, and any food containing gelatin with protein source not identified. Avoid touching fish, going to the fish market, and being in an area where fish is cooked. Seafood Allergy – Must avoid all types of seafood, fish balls, fish soup, and imitation fish. Do not eat in seafood restaurants if risk for anaphylaxis.

14. WHEAT ALLERGY Wheat is the most common allergy and the most difficult to avoid. Pasta, breads, cereal, pizza, baked goods all contain wheat. Batter or breading on meats and fish, meat loaf must be avoided. Most people allergic to wheat can tolerate oats and rye. Many flours on the market are also acceptable– rice, potato, oat, corn quinoa, tapioca. Corn Allergy – Avoid corn starch, corn sweetner, corn syrups solids, baking powder, tortillas, tamales, nachos, tacos. Celiac Disease – a digestive disorder that creates an immune reaction to the protein gluten. It causes inflammation in the small intestine. Individuals with celiac disease must avoid wheat, rye, barley, and sometimes oats.

15. ALLERGENS IN MEDICATIONS Inert ingredients -- Fillers, binders, and other ingredients in medications are common hidden allergens. They are difficult to avoid because of how medications are labeled. FDA regulations are not the same for foods and meds. Starch on a food label means corn starch. On a medicine label it could mean potato, corn, tapioca, or wheat starch. Maltodextrin can also be wheat. Sometimes pharmacists have to call the manufacturer to confirm ambiguous ingredients. Corn and wheat are two common allergens in excipients. Others include dairy products, potatoes, coconut, and gelatin. Arachis oil, a peanut derivative, is sometimes found in creams and topical medications.

16. ALLERGENS IN MEDICATIONS Yeast and Mold Allergens – B vitamins and multivitamin supplements with Vit B are derived from yeast. Penicillin and its derivatives are derived from fungi. Nickel Allergies – Vitamin and mineral supplements with nickel. Tyramine Sensitivity/Migraine Headaches – Avoid aged cheeses, raspberries, yeast extract, bananas, chicken liver, red plums, wine, avocados, beer, egg plant, fermented beverages, tomatoes, vinegar, pickles. Tartrazine – yellow dye or coloring. Medications, cosmetics, toiletries. Sulfites are found in many medications. Corn Allergy – IV solutions with dextrose may be contraindicated.

17. REFERENCES Vickerstaff Joneca, Janice. Dealing with Food Allergies, Bull Publishing, 2003. http://www.foodallergy.org/section/about-food-allergy http://www.foodallergy.org/page/milk-allergy# http://www.foodallergy.org/page/egg-allergy# http://www.foodallergy.org/page/peanut-allergy# http://www.foodallergy.org/page/wheat-allergy# http://www.foodallergy.org/page/soy-allergy# http://www.foodallergy.org/page/fish-allergy# http://www.foodallergies.about.com