Dietary management of food allergy & intolerance Dr Emilia Vassilopoulou BsC, PhD, Post-Doc Clinical Nutritionist Dietitian
Food Allergy An adverse immune response to a food protein Reactions to a food Toxic Non-toxic Psychological Immune-mediated Non-immune mediated IgE-mediated Non-IgE - mediated d Enzymatic Pharmacological l Other www.efa-net.org
Common food allergens A person could react to almost any food ~ 90 percent of food-related allergic reactions due to: Milk Eggs Peanuts Tree nuts (such as cashews and walnuts) Fish Shellfish Soy Wheat Pediatr Allergy Immunol. 2010 Jul 13
Natural history of food allergy ~50% children allergic tomilk, egg, soy & wheat outgrow allergy by the age of 6 still allergic by the age of 12 or so less than 8% chance outgrowing allergy Peanut & tree nut allergies less likely to be outgrown 20% peanut allergic 9% tree nut allergic J Allergy Clin Immunol. 2010 Mar;125(3):683-6
Increasing Prevalence of Food Allergy Food allergy (FA) 6-8% in the 3 first years of life 2% later up to adulthood 1/3 children with Atopic Dermatitis (AD) suffers later from FA (+) relation of FA with the occurrence of asthma Allergy 2009:64: 1407-1416
Is there a treatment? Individuals with protein allergies commonly avoid all forms of contact with the problematic protein promise for treatment: Immunotherapy (desensitisation) Areas of research on certain food allergies anti-ige antibody (Xolair) specific oral tolerance induction (SOTI) Immunotherapy. 2010 May 1;2(3):329-338
Brainstorming i on the proper child s diet Prevention risk children Nutritional support Children with food allergy Children with other atopic disease
Prevention: when? family history of food allergy personal history of atopic disease (AD, urticaria, asthma, food allergy 1 foods)
Practical advice Exclusive breast feeding Likely to reduce risk of FA occurrence ce No correlation between atopy and diet restrictions during pregnancy Acta Paediatr Scand 1983 May; 72 (3): 411 4 Acta Paediatr Scand. 1983 May; 72 (3): 411-4 Pediatrics. 2008 Jan;121(1):183-91
Hydrolyzed milk & elementary diet Partly or totally hydrolyzed milk o In the case of early interruption of breast feeding or initiation of mixed diet Allergy 2009:64: 1407-1416
Probiotics, Prebiotics, Sympiotics microorganisms of Gastrointestinal System (GI): significant role in the development of mucous & systemic immune system [bifidobacteria] + [chlostridium] in the GI of atopic children «control» intestinal flora of atopic children with alive microorganisms i (probiotics) i (lactobacillus, bifidobacterium) Non digested nutrients (prebiotics) (Galactooligosaccharides GOS, Fructooligosaccharides (FOS) Combination (symbiotics) (90%GOS+10%FOS: bifidobacteria) b i ) Allergy. 2007 Nov;62(11):1223-36
Maternal milk rich in oligosaccharides [bifidobacteria] & [lactobacili] potential protection of atopic disease in children During pregnancy and breastfeeding Supplement in infants & children 50% AD in children with allergic mothers who consumed probiotics i during pregnancy & lactation
Practical guidelines Avoid including solid food until 6 th month of life Mature GI & immune system gradual distributive entrance of new food in the diet: easy identification of allergic symptoms & responsible food Journal of Pediatric Health Care. July-August 2007; 21(4): 238-244 Pediatr Allergy Immunol 2007: 18: 250-257
New food introduction ti first trial: morning 1st administration: small portion of new food which gradually increases 1 new food every 6-7 days food mixtures (fruit or vegetable juices) only if the individual ingredients have previously consumed alone without a problem
6-9 months Solid food 1-2 times per day Gradually increase to 3-4 times per day Grains & cereals rice- & corn-flour (iron fortified) Vegetables potato, sweet-potato potato, carrot, vegetable marrow, french bean, beetroot Fruit pear, apple, banana First cooked/ boiled or compote Later raw but peeled
Solid food 5-6 times daily 9-12 months Grains & cereals Flours of wheat, rye, oats, barley & their products (fortified with iron) Vegetables Broccoli, cauliflower, spinach Fruit peach, apricot peeled Egg Only yolk Fat Olive oil, vegetable margarine
After 12 months Legumes Fruits With the peel, citrus fruit, strawberry, fig etc. Nuts Egg Fish White fish, salmon, sardines, cod (fresh fish not frozen) In the case of AD or other FA delay introduction ti of egg white, raw egg & fish Ann Allergy Asthma Immunol. 2006 Jul;97(1):10-20; 77 Pediatr Allergy Immunol 2007;18: 250-257
Personalized advise Despite the general guidelines regarding g the order of new food introduction in the child s diet every child is unique & could react to any food type even if it is considered d as a low allergenic food avoid extreme food exclusion especially in children with AD Need for objective diagnosis Food Chem Toxicol. 2004 Dec;42(12):2037-44
Diagnosed Food Allergy Elimination (exclusion) diet 3 main types: 1. single-food exclusion 2. multiple-food exclusion 3. the "Few Foods" (Oligoallergenic Diet) Defined by Clinical history & examination Patient s age In-vitro tests (blood tests) Proc Nutr Soc. 2006 Nov;65(4):412-7
Why so much concern? Dietary limitations i i secondary to food allergy can lead to failure to thrive deficiencies in specific macro- & micro- nutrients Social restriction/ psychological problems Several studies food allergic children have lower intakes of total energy & macro/micronutrients Adults deny to socialize/ eat out due to fear Pediatr Clin North Am. 2009 Oct;56(5):1085-103. Review
Balanced diet Monitoring patient s compliance Prevent accidental allergic reactions Ensure adequate nutrition within the context of the allergen-restricted restricted diet Normal growth (ΒΜΙ, growth charts) Can J Diet Pract Res. 1999 Winter;60(4):222-230
Nutritional assessment Goal: prevent nutritional ii disorders d & the increased morbidity & mortality that accompany them 5 step quantitative evaluation of nutritional status Dietary, medical & medication i history Physical examination Growth, anthropometric & body composition measurements Laboratory tests Intervention & monitoring Pediatr Allergy Immunol. 2010 Jun 14
Result.. Educate & support patients & family Allergen free recipes Alternative food- sources of basic nutrients for a balanced diet Appropriate food supplements Read food labels/ recognize food allergen Proc Nutr Soc. 2006 Nov;65(4):412-7
Food allergen labeling Difficult to find safe pre-packed food products Educate patients to Read food label Decipher/ recognize potential allergens J Allergy Clin Immunol 2007;119:1504-10
Different ways of labeling basic allergens in selected pre-packed food products of the Hellenic Market Starch 45 Milk 30 Egg 6 Sesame 2 Tree nuts 9 Peanut 4 Soya 3 Vassilopoulou, et al. Peadiatriki. 2009;2:24-28
Potential ways of labeling 3 common food allergens Milk: whey, casein, rennet, high protein content flour, nougat special attention to vegetable-source products such as chocolates, vegetable-margarine, soya-cheese, tofu, sugar candies Egg: albumin, provitamin A, coagulant, emulsifier might be contained in a product and not labeled eg in breads & cakes when spread before baking Starch: transmutant starch, cuscus, hydrolyzed vegetable protein, dextrin, maltodextrin, gluten, gliadin, spice, stabilizer Vassilopoulou, et al. Peadiatriki. 2009;2:24-28
Food Intolerance involves the body's metabolism not the immune system Enzymatic, pharmacological, other.. http://www.foodintol.com/
Lactose intolerance lack the digestive enzyme lactase breaks down the milk sugar lactose free products Ann Intern Med. 2010. www.annals.or
Gluten intolerance the body can't tolerate gluten protein found in wheat, rye, barley & probably bl oats permanent condition can be diagnosed at any age Prevalence of coeliac disease (or gluten-sensitive enteropathy) is underestimated serological testing detects undiagnosed disease in 1/100 individuals in the European population Ann Intern Med. 2005;142:289-298
Coeliac disease Pathophysiology: sufferer consumes a gluten- containing food lining of the small intestine becomes damaged less able to absorb essential nutrients (fats, protein, carbohydrates, minerals & vitamins) Ann Intern Med. 2005;142:289-298
Coeliac disease Symptoms: diarrhoea, weight loss weakness, irritability & abdominal cramps In children, symptoms: malnourishment including growth failure only help for coeliac patients is a gluten-free diet (available local dietetic & coeliac disease information centres & associations) gluten removed from the diet, the intestine gradually repairs itself symptoms disappear Ann Intern Med. 2005;142:289-298
Celiac disease Research efforts to identify the exact nature &sequence of amino acids in the gluten result in celiac disease future important application of biotechnology development of cereal crops that do not cause intolerance
Food Additives food additives pose no problems for most people small number of people with specific allergies also sensitive to certain food additives (certain colours & sulphites) food additives must be clearly labelled those with specific sensitivities to a food additive can readily avoid any that may pose problems www.caobisco.com
Summary Role of dietitian: very important in food allergy & intolerance management Diagnosis i (provide appropriate elimination i i diet) Plan meals healthful & nutritious without including the potentially allergenic foods Educate on reading food labels / safely eating out Advice & support families according their hi circumstances in the day-to-day management of diet remains varied & enjoyable available alternative foods provision of 'free-from' recipes guidance on nutritional supplements needed to meet nutritional needs