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 S. No.DiseaseTotal CasesDeathsYear 1Acute Respiratory Infection1,18,54,34537362007 2Acute Diarrhea Disease94,78,81323282007 3Measles269861995 4Malaria136327910662007 5Japanese Encephalitis40179892007 6Dengue5395692007

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 Toxic / Pharmacologic Non-Toxic / Intolerance Bacterial food poisoning Heavy metal poisoning Scombroid fish poisoning Caffeine Alcohol Histamine Non-immunologic 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. Eosinophilic esophagitis Eosinophilic gastritis Eosinophilic gastroenteritis Atopic dermatitis Adverse Food Reactions IgE-Mediated (most common) Non-IgE Mediated Cell-Mediated Immunologic Systemic (Anaphylaxis) Oral Allergy Syndrome Immediate gastrointestinal allergy Asthma/rhinitis Urticaria Morbilliform rashes and flushing Contact urticaria Celiac disease Protein-Induced Enterocolitis Protein-Induced Enteropathy Eosinophilic proctitis Dermatitis herpetiformis Contact dermatitis

10. 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

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. Food allergy IgE-mediated food allergy Non-allergic food hypersensitivity Non IgE-mediated food allergy Foodhypersensitivity Food allergy IgE-mediated allergy Non-IgE- mediated e.g. celiac disease Non-allergic-food hypersensitivity Enzymatic - lactose intolerance Pharmacological - biogenic amines e.g. histamine, tyramine

14. Allergens from a single site No. of Tests- 66778 (2008 & 2009) Name of AllergenPercentage allocation Mite36.1 Cockroach32.5 Asp.Fum.28.8 H.dust21.8 Bermuda grass21 Shrimp18 Johansson grass15.9 Wheat12.4

15. IgE mediated Food Allergens in patients with Asthma and allergic rhinitis. No. of patients- 1860 patient. Curd48 % Rice43% Citrus35 % Banana27 % Milk12 % blackgram9.7 % Egg2.7 % Chicken1.5 % Fish1.2%

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, 1 st 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