Transcript NUT2_PowerPoint_Allergies_and_food_intolerances

ALLERGIES
AND
FOOD INTOLERANCES
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.
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• 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
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Overview
Presentation
Food Allergy
Coeliac Disease
Food Intolerance
Infantile eczema
Fatigue
Acute Reactions:
•Rash around
mouth
•Hives/swelling
•Vomiting
•Breathing
difficulty
•Anaphylaxis
GI:
•Bloating
•Cramps
•Diarrhoea
Episodic/recurrent:
•Hives/swellings
•Stomach/bowel
irritation
•Headaches/migraine
•Fatigue/aches/pains
•Mouth ulcers
•Sinus congestion/
polyps
•Anaemia
May be
asymptomatic
In Children:
Irritable behaviour –
colic, screaming,
disturbed sleep, leg
aches & pains ADHD
Reflux from birth
Eczema itchy rashes
Nappy rash
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Food Allergy
Coeliac Disease
Food Intolerance
Age of onset
Infants & toddlers
Mostly
Any age
Any age
Family Hs
Atopic – asthma,
eczema, hay fever
HLA Gene
Association coeliac diabetes,
thyroid
Commonly IBD
hives, headaches,
mouth ulcers
Reaction
immediate, min to
1-2hrs
Reproducible
Chronic
Reproducible
Hours – days
variable
Mechanism
Immune IgE
antibodies
Immune
inflammatory T
Cells
Non immune
irritation of nerve
endings
Food triggers
Specific foods
proteins
Gluten
Natural food
chemicals
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Food Allergy
Coeliac Disease
Food intolerance
Tests
Skin prick test,
blood tests (RAST)
measure IgE to
specific allergens
Must be eating
gluten:
Ab to
transglutaminase
Small bowel biopsy
to confirm Dx.
Elimination Diet
food chemical
challenges
Dietary
Management
Complete avoiance
of single foods
Gluten free diet –
strict
Comprehensive
dietary
modification to
maintain a chemical
load below reaction
threshold
Outcome
Egg, milk, usually
outgrown.
Peanut, tree nuts
and seafood often
persist (70-80%)
Life long immune
reactivity
Bowel pathology
and Ab usually
return to normal on
gluten free diet
Life long
susceptibility.
Variable tolerance
Symptoms can
come and go.
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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
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• 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.
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• 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
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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.
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• 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.
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(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.
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COELIAC DISEASE
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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.
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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
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•
•
•
•
•
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
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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
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• 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
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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.
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• 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.
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Foods containing chemicals/Chemical Load
Additive Effect
Threshold/
Symptoms
juice
banana
cheese
Time/dose
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• 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.
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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
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 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
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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.
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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.
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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.
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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.
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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
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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.
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– 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
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• 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.
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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.
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Diagnosis Pathway
Elimination
Diet
Symptom
Free
No Response
Normal
Diet/FODMAP
2- 6
Weeks
DBPC
chemical
Challenge
 5 well
days
Open Food
Challenge
Individualised
Diet
6-8 weeks
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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.
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• 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.
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• 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.
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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
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FODMAPs
• Fermentable
• Oligosaccharides -
Fructans,
Galacto-oligosaccharides (GOS)
•
•
•
•
Disaccharides Monosaccharide
And
Polyols
Lactose
Fructose in excess of glucose
sorbitol
manitol
These are all CHO based foods with sorbitol and manitol being
sugar alcohols.
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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
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NOW WHAT???
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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.
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Shared Symptoms, Different Reaction
IgE
Food Allergy
Coeliac
Disease
Food
Intolerance
T Cell
Mediated
Non-Immunological
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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
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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
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Patient presents with symptoms
and food history
Other Diagnosis
Assess Alarm Features
Appropriate Treatment
Coeliac Testing and
other Testing
Functional Bowel Disorder
no
RPAH Elimination
Diet
yes
Breath hydrogen & methane with fructose
and lactose to assess absorptive capacity
Restriction of lactose if lactose
malabsorption present
Complete FODMAP restriction
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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.
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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
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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.
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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.
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• After 3 years of age, 33% outgrow them in the next 3 years.
• For others, it will most probably be lifetime
• Perform regular controlled food challenges (Jamison p.147)
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Coeliac Disease
• Must avoid all gluten containing products which include
whole grains and their products from Wheat; Rye; Barley and
for some, Oats.
This interprets to:
• Breakfast cereals, breads and toast;
• Muslie bars, grained bars;
• Cakes, pastries, biscuits made from the above flours
• Pasta, in most forms, cous cous, semolina, spelt, triticale,
wheatgerm, bran & meal
• Wheatened cornflour, modified starch,
• Malt and extracts, Malt vinegar
• May contain – beverage whitener, dextrin, maltodextrin
thickeners 1400-1450
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• From their food diary, show them their sources of gluten,
offer the alternatives;
• Grains such as rice, polenta, sago, sorghum, soy
• Baked goods using
– Arrowroot, buckwheat, corn maize, millet, pollenta
– Rice, sago, soy, tapioca
• Fibre from psyllium, LSA, slippery elm, and ‘greens’ if
additional is required.
• There are plenty of products in the supermarket, and also in
the shops that can meet most needs.
• Recipe books are also plentiful to help a person make things
from scratch.
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Food Intolerance
Follow the principles of the RPAH elimination diet which include:
• Determine the severity of the reactions and negotiate how
strict the elimination period will need to be.
• Individuation will be guided by
• Clinical pattern – frequency and severity etc
• IBS – exclude milk, wheat, so and windy foods
• Personal preference – strict, moderate, simple
• Personal circumstances.
• Need to include only those foods indicated in the charts –
RPAH protocol
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Challenge Phase
• When the client is symptom free for at least 5 days
reintroduce a food that contains only that chemical you have
chosen to test. Keep in mind the following:
• Do not give a client a known allergen such as wheat, milk,
seafood, nuts etc or if they have had a severe reaction in the
past such as throat or tongue swelling or difficult to breathe
• How much to eat
– Reactions are dose dependent
– Eat as much as possible spread over the day
– Do not use known trigger foods identified during history
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• How long to continue?
– Up to 7 days for milk, wheat, soy, salicylate, amines
– Up to 3 days for msg, preservatives colours
• Children
– May not be able to eat the amounts recommended
– Give them as much as possible
– Continue for 7-14 days unless symptoms develop
• Going onto the next challenge
–
–
–
–
Beware of refractory period (2-3) days
3 full days in a row symptom free
Be patient, do not rush challenges
If uncertain repeat the challenge 2-3 times.
• For each challenge monitor and record all changes to body
and mind.
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Cows Milk Challenge 7 days
• Choose milk from drinks list
• Build up to 3 cups of cow’s milk/day over a day or two
• If no reaction after 7 days,
– You can leave milk and low chemical dairy products in your diet
during other challenges.
Do not give a client cows milk if
• known allergy to milk,
• or if they have had a severe reaction in the past such as
throat or tongue swelling or difficult to breathe
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Soy Drink  7 days
• Choose soy drinks for the list provided
• Build up to 3 cups of soy drink per day over a day or two
• If there is no reaction after 7 days, you can leave soy drink and
low chemical soy products in your diet while you proceed with
the other challenges.
Do not give a client soy milk if
• known allergy to soy,
• or if they have had a severe reaction in the past such as
throat or tongue swelling or difficult to breathe
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Wheat  7 days
• Choose from the list provided
• Eat at least
– 1 cup plain cooked pasta per day
And
– 12 plain water crackers (antioxidant free)/day
• If there is no reaction after 3days, add
– 4 slices of bread (no preservatives or vinegar)
• If there is no reaction after 7 days, you can keep low chemical
wheat products in your diet while you proceed with the other
challenges.
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Natural Salicylates 7days
• Eat at least 6 serves per day, chosen from different foods in
any combination
• Fruit
– 1 large granny smith apple*
– ¼-1/2 rockmelon *
– 1 large slice watermelon*
• Vegetables
–
–
–
–
6-8 asparagus spears
½-1 cucumber
1 cup pumpkin
1 cup sweet potato
1 medium zucchini
1 cup carrot
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Cont.
• Sweets
– 1 Table spoon honey*
– 10 pepp-o-mints life savers
• Spices
– 1 teaspoon curry powder
• Drinks
– 150ml apple juice
unpreserved
– 1 cup strong tea
– 1 cup peppermint tea
• * foods containing Fructose
and Salicylate
• In patients with IBS test
response to fructose first –
mango
• If fructose causes a
reaction, limit the intake of
these foods during the
salicylate challenge
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AoCH 2011. use without written
permission prohibited.
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Natural Amines  7 days
• Eat at least
– 2-3 large ripe bananas
– 60-120g plain, dark chocolate
• In addition, choose freely from
–
–
–
–
–
–
–
Cocoa powder and drinking chocolate,
Pawpaw
Pork (not ham or preserved meats)
Salmon canned
Sardines canned
Tuna canned
If milk is tolerated, 60-120g mild yellow cheese
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Glutamate 3days
• MSG 621
• If amines are tolerated,
– 4 Tablespoons of soy sauce mixed into rice or meatballs
– Parmesan cheese sprinkled liberally (if milk is tolerated)
• If salicylates are tolerated
– 500ml chicken noodle packet soup
• If amines and salicylates are not tolerated
– Chicken salt on preserved chips.
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Food Additives 3days
• Propionate 280-283
–
–
–
–
4 slices of bread containing these.
3 English muffins
3 crumpets
2 bake at home rolls
• BHA/BHT 310-312, 319-321
– 2 small macdonold fries
•
Nitrite 249-252
–
4 slices of bacon
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cont
• Benzoate 210-218
– Sprite
• Sorbate 200-203
– Spreads and dips
• Sulphate 220-228
– Preserved foods using these
• Colourings 102, 107, 122-129, 131-132, 142, 151, 154-155
– Musk sticks, cordial, food colouring
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FODMAPS
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permission prohibited.
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Challenge Procedure
• Restrict known or suspected mal-absorbed FODMAPs until
adequate symptom control is achieved and maintained, appro
6-8 weeks.
• Reintroduce foods in controlled amounts to best balance food
restriction with symptoms
• Keep in mind that some are partly absorbed
– Fructose,
– Lactose
– Polyols
• Some are not absorbed in everyone
– Fructans
– GOS
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Steps
•
•
•
•
•
Initially use foods that contain only one FODMAP
Eat challenge food at least twice during the test week
Use the same food and quantity for the week
Monitoring symptom response in diary may be useful
You may then like to reintroduce small serves of foods
containing more than one FODMAP
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If the client is symptom free
• Gradually increase the number of foods that contain the
FODMAp you are challenging, and continue to assess
response
Or
• Maintain the amount and type of food you have challenged
and then continue to the next FODMAP challenge.
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If client is getting symptoms
• Wait until symptom free, reduce the serving size to half and
challenge again
or
• Assume the food is a problem food
– Severe symptoms during a food challenge they most likely have
a very sensitive irritable bowel triggered by that particular food
and will likely have to continue restriction
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Other points of interest
• Problem foods
– It is likely the client does not have to omit the FODMAP
completely, the dose is of value.
– Try another food from within the same FODMAP group
– Rechallenge after a period of time the body may heal or adjust
– Relax on the restriction when eating out and allow informed
eating choices ie symptoms vs the social value of the outing
• Benefit of challenging is it opens up the food choices and they
don’t need to over restrict,
– Mininises deficiency and food boredom
– Allows pleasure. Chocolate cake
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cont
• Restrictive diets, even well planned ones run the risk of
nutritional inadequacy
• Important to include as much variety with in the tolerated
foods while still controlling symptoms
• Ensure any food or food type is replaced
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Order of Challenge
• Mannitol
– ½ cup mushrooms
– 1/3 cup cauliflower
• Sorbitol
– 2 fresh apricots or 4 dried halves or
– 1 medium nectarine or
– 2 peices sugar free chewing gum (artificially sweetened with
sorbitol
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• Lactose if suspected
– ½ cup low fat milk or
– 200g tub yoghurt
• Suspected fructose
– 1 cheek of mango or
– 3 tsp honey
• Suspected wheat fructans
– 2 slices wholemeal bread
• Garlic and leek fructans
– 1 clove garlic
– ½ leak both green and white
• Onion fructans
– ¼ cup onion or
– For very cautious people,
suggest cook with onion
and not eating it.
– Don’t restrict onion when
eating out.
• GOS
– All legumes
– Most important for
vegetarians
– ½ cup canned and drained
legumes
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permission prohibited.
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For All Situations
• Education must be given in relation to
– Adequate kj and nutrients while on the elimination and
challenge phase of the protocol
– Reassure the client what is happening.
– The know foods that carry the suspected and then confirmed
chemical or compound.
• how to recognise the confirmed chemical or compound
when eating out, shopping for food.
• Strategies of how to minimise social difficulties including
parties, eating out, travelling
• Encourage cooking from scratch as most of the offending
chemicals and compounds are in processed/packaged foods
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