Transcript Food Allergy

Adverse Food Reactions & Inflammation
Understanding the Connection and Empowering
Patients to Heal from the Inside Out
BY ERIN PEISACH, RDN, CLT
OWNER OF
Objectives





Briefly review the immune system as it relates to
inflammation.
Highlight the connection between inflammation, adverse
food reactions (AFR), and disease.
Explain various types of AFRs, emphasizing immunemediated reactions, and review diagnostics, symptoms
and treatment options.
Outline the tools RDNs may provide their patients with AFRs
to help reduce inflammation, improve symptoms, and
promote the healing process.
Review an AFR case study.
The Immune System
Purpose of The Immune System:

Immune cells and other components fight invaders
to keep the body healthy and safe

Invaders: bacteria, viruses, parasites, & food

Military Personnel:
My Kindergarten take on the topic
•
White Blood Cells:
•
•
Antibodies:
•
•
Mast cells, basophils, eosinophils, lymphocytes,
neutrophils, monocytes, macrophages, T-cells, NK-cells
IgE, IgG, IgM, IgA, IgD
Complement System:
•
C3, C4
•
Platelets
•
Chemical Mediators
•
Histamine, prostaglandins, serotonin, cytokines, leukotrienes, etc.
Immune System 101

Innate
 Involves
 First

barriers
line of defense
Adaptive
 Prevents
indiscriminate
responses to harmless
antigens
 Long
lasting defense
Gut Immunology

GI tract has two major roles:
 Digestion
nutrients

and absorption of
Immune homeostasis

Constantly exposed to chemicals,
proteins, bacteria, & antigens

Separates the external environment
from the internal environment
The gut ultimately must decide:
friend or foe?
Gut Immunology
Gut
associated
lymphoid
tissue (GALT):
Aka The Gut
Immune
System
Largest
immune
organ in the
body
Definitions:


Intestinal barrier: is a functional entity separating the gut
lumen from the inner host
Intestinal permeability: a functional feature of the
intestinal barrier at given sites

Normal: stable permeability found in healthy individuals with no
signs of intoxication, inflammation or impaired intestinal functions

Impaired: a disturbed permeability being non-transiently
changed compared to the normal permeability leading to a loss
of intestinal homeostasis, functional impairments and disease
Bischoff et al. BMC Gastroenterology 2014 14:189
Intestinal Permeability

Impaired intestinal barrier integrity in the colon of patients with
irritable bowel syndrome: involvement of soluble mediators. – 2008
study in BMJ
 Conclusions:
“Our study shows that colonic soluble
mediators are able to reproduce functional
(permeability) and molecular (ZO-1 mRNA expression)
alterations observed in IBS patients.”
Healthy Digestive Pathway

Digestion of food begins in the
mouth, then travels to the stomach

Food/proteins interact with gastric
acid and enzymes, turning into
smaller particles ready for absorption

Once the particles (antigens) pass
the epithelium barrier, the immune
system typically expresses oral
tolerance

The GALT is tightly regulated to
prevent excessive immune responses
Oral Tolerance

Definition: Active systemic suppression of cellular or humoral immune
responses to an antigen following prior administration of the antigen
by the oral route

Impacted by:

Antigen specific elements

Age

Genetics

Intestinal microbial environment

Changes throughout the lifetime

Loss of oral tolerance triggers immune reactions that may cause
adverse food reactions and pathological conditions
Inflammation
Inflammation- to set on fire (Latin)

Acute inflammation

Natural and essential for health

Defend, fight, repair, & heal

Caused by short term injury



Tissue injury, infections, immune reactions
Symptoms: heat, redness, swelling, pain, loss of
function
Chronic inflammation

Long term damaging to health

Related to disease, illness, and reduced
quality of life

Caused by on-going injury


SAD diet, nutrient deficiencies, obesity, stress
Symptoms: chronic pain, allergies, fatigue,
altered blood sugar, cancer
Inflammation & Disease
Metabolic:
• Metabolic
Syndrome
• Obesity
• Type 1 Diabetes
• Type II Diabetes
Pulmonology
• Asthma
• Anaphylaxis
Musculoskeletal:
• Fibromyalgia
• Rheumatoid Arthritis
• Reactive Arthritis
• Chronic Fatigue
Syndrome
Dermatological:
• Atopic Dermatitis
• Dermatitis
Herpetiformis
• Urticaria
• Psoriasis
Neurological:
• Migraine
• ADD/ADHD
• Autism Spectrum
Disorder
• Epilepsy
• Depression
• Insomnia
• Multiple Sclerosis
Gastrointestinal:
• Cyclic Vomiting
Syndrome
• Functional Diarrhea
• Irritable Bowel
Syndrome
• Lymphocytic Colitis
• Crohn’s Disease
• Ulcerative Colitis
Urology
• GERD
• Interstitial
• Celiac Disease
Cystitis
• Systemic Lupus
Endocrinology
• Hashimoto’s
• Grave’s Disease
Steps to Consider to Reduce
Inflammation:
Identify
inflammatory
triggers
Remove
triggers
Heal the gut
& boost the
immune
system
Reduce
inflammation
Support
sustained
improvement
in disease,
illness &
symptoms
Inflammatory Triggers

Psychological


Environmental


Sedentary lifestyle, tobacco/drug/alcohol use, lack of sleep
Dietary choices


Mold, pollution, lack of outdoors/sunlight, allergens, toxin exposure
Lifestyle Choices


Stress, depression, anxiety
Adverse food reactions, inadequate nutrient intake, excessive intake of
poor quality/processed foods
Other

Overweight/obesity, genetic predisposition
How Food Sensitivities Cause Inflammation
There is a strong connection between
gastrointestinal health, immune
system function, inflammation, and
adverse food reactions.
Adverse Food Reactions
Adverse Food
Reactions (AFR):
AFR
Toxic
Non Toxic
Food
Contaminant
Immune
mediated
Allergy
Sensitivity
Celiac
Non-immune mediated
Intolerance
Aversion
Irritants
Histamine
Lectins
SIBO/Dysbiosis
Enzyme
Deficiencies
NonImmunologic
Reactions
Malabsorption
(FODMAPS)
Toxic
Reactions
IMMUNE
REACTIONS
ALLERGIES
TYPE 1
Antibody
mediated
(IgE)
SENSITIVITIES
TYPE 3
Antibody
Mediated
(IgG, IgM)
TYPE 4
Cell Mediated
Food AllergyType 1 Hypersensitivity
Food Allergy

Impacts ~6% of children and 3.7% of adults

Risk factors:


family history

male sex

genetic polymorphisms

early infectious exposure

rural upbringing with exposure to animals and livestock (protective)

pathogenic microorganisms

gut mucosa

antigenic characteristic of food proteins (size, abundance, resistance to
acidic and enzymatic denaturation and digestion, immunogenicity)

sanitary living
No prevention strategies known at this time
Food Allergy

Most common allergens (accounts for >90% of cases in children):

Hen’s egg

Cow’s milk

Peanuts

Soybean products

Wheat

Tree nuts

Fish

Shellfish
Food Allergy

Symptoms

Skin- itching, hives, angioedema, flushing

GI- oral itching, nausea, vomiting, diarrhea

Nasal/respiratory tract- nasal congestion, runny nose, itchy eyes/nose,
sneezing, laryngeal edema, wheezing, shortness of breath

Cardiovascular system- light headedness, syncope, hypotension

Oral Allergy Syndrome

Most common food allergy in adults

Examples: birch-fruit/veggie, celery-birch-mugwort, ragweed-melon/banana

Generally more mild symptoms primarily in the oropharynx

Lip/mouth itching, swelling, hoarseness, rhinitis, etc.
Food Allergy- Testing

Begin assessment with thorough clinical history and physical exam

Patient will typically report reproducible symptoms occurring after
exposure to a food
In vivo testing (SPT/Scratch test): skin test

Oral Food Challenge

The definitive, gold standard test
In vitro testing (RAST/ELISA): blood test
Food Allergy- Treatment

Remove food from the diet completely, including cross
contamination exposure

Consider oral food challenge (ideally double-blind, placebocontrolled)

Weigh the risks (anaphylaxis, other symptoms) and benefits (nutritional,
social, quality of life)

Medical supervision

Protocol: 1-6 weeks (varies based on severity) elimination followed by
monitored/controlled food reintroduction

Limitations: concerns about safety, time, reimbursement, lack of
space/time
Food SensitivityType III & IV Hypersensitivity
Food Sensitivity

Type 3 & 4 immune-mediated reaction

Develops after loss of oral tolerance

No set list of common reactive foods

Dose-dependent reaction

Delayed reaction time (4-72 hours post-ingestion)

Patient is likely to have more than one reactive food (typically 1020)

Symptoms vary- impact the body anywhere blood flows

Difficult to identify/diagnose- more research is needed
Food Sensitivity (FS)

May be associated with:
 Intestinal
dysbiosis
 Increased
gut permeability
 Stress
 Anxiety/depression
 Immunological
and local factors
FS Symptoms

Systemic symptoms

Patients typically report multiple
symptoms
Food Sensitivity- Testing

No test is currently supported by strong evidence



ELISA IgG or IgG4 Antibodies

Quantifies the level of IgG response to specific foods

Tests foods only, not food chemicals

Elevated IgG may be harmful or protective
Antigen Leukocyte Cellular Antibody Test (ALCAT)

End-point blood test that quantifies mediator release (i.e. histamine, cytokines,
prostaglandins, etc.)

Tests both foods and food chemicals

Poor split sample reproducibility, low accuracy, outdated technology
Mediator Release Test (MRT)

Similar, but updated ALCAT technology

Tests both foods and food chemicals

94.5%sensitivity, 91.7% specificity (high accuracy) and >90% split sample
reproducibility (high reliability)
“ Food specific IgG antibodies in serum are not of clinical
importance but merely indicate a previous exposure to
the food.”
-Krause’s Food Nutrition and Diet Therapy 2008
IgG “is a marker of exposure and tolerance to food…”
-Canadian Society of Allergy and Clinical Immunology
“…the direct clinical meaning of food IgG testing is not
known. The industry needs more extensive clinical research
in this area.”
-Aristo Vojdani, PhD, MSc, CLS, Alternative Therapies 2015
How MRT Works
Food Sensitivity- Treatment

Elimination Diet (at least two weeks)

Specific Foods
 Low

FODMAPS, gluten, dairy, nightshades, soy, etc.
Oligoantigenic/Selected Foods
 LEAP

protocol
Elemental

Oral Food Challenge

Heal/repair the gut

Rotation Diets?
Examples of Elimination Diets

Rowe Elimination Diet:


Institute of Functional Medicine Diet:


avoid gluten, corn, soy, dairy, shellfish, beef, pork, peanuts, eggs,
oranges, refined sugar
Lifestyle Eating And Performance Diet (LEAP)


5-10 foods only
6 Phase-diet based on results of MRT testing and clinical history
SWAG Diet:
Commonly Eliminated Foods
Fatty meats: beef, pork, veal
Eggs
Dairy and products made from dairy
Gluten and products made from
gluten
Corn and products made from corn
Alcohol/Caffeine
Foods containing yeast or promoting
yeast overgrowth: processed foods,
refined sugar, cheese, peanuts,
vinegar
Simple carbohydrates: sugar, “white”
flour, processed foods, soda
Unhealthy fats: margarine,
shortening, butter
Peanuts
Strawberries and citrus fruit
Foods with high FODMAPs: apples,
onions, dairy, legumes, etc.
Additives and preservatives
Soy and products made from soy
Summary of Immune-Mediated
AFRs
Food Allergy
Food Sensitivity
What Is It?
Generally Quick Immune Reaction
That Results in Hives, Asthma,
Swelling of Airways, Vomiting
Often Delayed Immune Reaction That Results
In Chronic Health Problems Like IBS &
Migraine Headaches
Unique Characteristics:
Quick Reaction
Anaphylactic Shock
Single Mechanism (IgE)
Delayed Reaction
Can Be Dosage Related
Multiple Mechanisms
Difficult to Identify Culprits
Cells Involved in
Reaction:
Mast Cells
Possibly Basophils
T-Cells
NK Cells
Neutrophils
Monocytes
Eosinophils
Basophils
Platelets
Mechanisms Which
Trigger Mediator Release:
IgE
IgG, IgM, IgA
C3, C4
Immune Cells
Lectins
Toxins
Dietitian Toolbox
Toolbox:
1.
Help the patient identify inflammatory
triggers/problematic foods
2.
Design a systematic and effective elimination
diet
3.
Assess patient progress over time
4.
Continue to help the patient heal, repair, and
relieve inflammation through nutrition and
lifestyle interventions
1. Help the patient identify
inflammatory triggers

Complete a thorough clinical and family history

Review the patient’s food and symptom diary

Request appropriate testing as needed
 Food
Sensitivity?  MRT
 Food
Intolerance?  Breathe Test
 Food
Allergy?  IgE skin prick or blood test
2. Design a systematic and
effective elimination diet

Decide on the optimal dietary plan
 Will the patient comply?
 How severe are their symptoms?
 What

previous diets have they tried?
Create a systematic approach
 Stay organized
 Avoid
conflicting advice (i.e. FODMAP lists, elimination
protocols, celebrity diet-gurus, etc.)
 Be direct, yet flexible
LEAP Elimination Diet



20-25 of the best and “safest” foods for ~14 days (Phase 1)

Patient agrees to consume the food and has consumed the food previously

No intolerances to the food

Food must be accessible and nutritionally valuable
Progress the diet systematically after significant symptom improvement
is reported/documented. Foods to progress the diet can be based on:

Specific food preferences/accessibility

Nutritional value

Likelihood of tolerance

Slowly- one new food every day or even every week
Document the “oral food challenge” in a food/symptom diary
Example:

Input TESTED foods into
each of the 5 phases

Each food listed can be
consumed in any “form”
(i.e. apples, applesauce,
apple juice, apple cider
vinegar, etc.)

Each phase, beyond
phase 1 lasts at minimum 5
days

Untested foods will be
reintroduced after phase 5

The entire process may
take >2 months
Food & Symptom Diary
 Monitor
adherence to
the diet
 Keep the
patient
engaged and
accountable
 Track even
minute
changes over
time
 Detective
Work!
Date/Time
Meds/
supplements
taken
Food Eaten, Amounts and Description:
brand preparation, etc.
Symptoms?
What and how severe (1-10)
Cytokine Profile of Individual D-IBS Patient
IBS-D PATIENT PLASMA CYTOKINES DURING D-EPISODE v BETWEEN EPISODES
350
1 IL-2
2 IL-4
300
3 IL-6
4 IL-8
250
5 IL-10
200
pg/ml
Series1
Series2
Series3
150
6 GM-CSF
7 IFN-g
8 TNF-a
9 IL-1b
100
10 IL-5
11 IL-7
50
12 IL-12
13 IL-13
0
1
2
3
4
5
6
7
8
9
10
11
12
See Specific Cytokine Key
Patient on LEAP diet
Patient off LEAP diet
13
14
15
16
14 IL-17
15 G-CSF
16 MCP1(MCAF)
3. Assess patient progress over time
 Baseline- report symptoms
over the previous month
(0-4 rating)
 Follow up- after 2 weeks
on the program, monthly
basis thereafter
 Record progress
*Patients tend to “forget
how they felt” so you must
remind them!
4. Help the patient heal, repair,
and relieve inflammation

AFRs are just ONE piece of the complex inflammation puzzle

Address other underlying inflammatory triggers

Develop a sustainable, healthy, anti-inflammatory maintenance
plan

Varied, balanced diet

Modify food preparation techniques, food quantity, and intake
frequency

Weight management as needed

Nutritional supplements as needed
Anti-Inflammatory
Recommendations:
 Fats
 Omega 3s, monounsaturated fats
 Avoid fried foods and hydrogenated fats
 Whole foods
 Antioxidant/colorful foods, herbs, spices
 High fiber
 Reduce intake of processed foods
 Physical activity
 Avoid a sedentary lifestyle
 10,000 steps per day
 Flexibility, strength, aerobic exercise
 Sleep
 7-9 hours of good quality sleep
 Nap as needed
 Reduce toxin exposure
 Limit caffeine and alcohol
 Live a “natural” life
 Stress management
 Practice mindfulness each day
 Drink plenty of purified water
 Achieve a healthy weight
Case Study- MC

53 year old female, works as a librarian

Medical History: allergies, menopause, chronic low back pain, joint
pain, IBS

Medications: albuterol, bupropion, Allegra, Flonase, D3 1000

BMI= 25.26, overweight

Generally appears healthy, exercises regularly, sleeps well, manages
stress

MC’s Health Goals: improve pain, reduce allergic-type symptoms,
improve digestive health
Case Study- MC

Diet description: low carb, high protein (fish, chicken, eggs), limits dairy,
frequent consumption of fresh greens, 3 glasses of wine 2-3x per week,
1-2c coffee daily

No known food allergies, but avoids wheat, hot peppers and
cucumbers related to digestive concerns

Symptoms: sinus congestion/cough/itchy eyes despite year round use
of Allegra, daily gas and bloating, heartburn, fatigue, headache,
others…


Initial Symptom Survey= 69
Intervention:

Start with specific food elimination diet: gluten, dairy, sugar, soy

Assess progress. If limited improvement, try olio-antigenic diet (LEAP) based
on MRT results
Case Study- MC

INPUT results
Case Study- MC

Phases 1-5

Phase 1: 2 weeks, baseline diet

Phases 2-5: minimum of 5 days each


Add 1 new food each day (or slower!)
Use the food plan to develop a menu plan:

B: Hot quinoa flakes in soy milk, add maple
syrup, chopped walnuts, and sliced strawberries.
Seltzer water with a few raspberries.

S: Hard-boiled egg

L: Steamed shrimp over cooked quinoa or
amaranth, with a side of blanched string beans,
toss in sesame oil and toasted sesame seeds.

S: Dry roasted or steamed edamame

D: Baked tofu (marinade in tamari, turmeric,
tahini paste, oil). Side of roasted yellow squash.

S: Hot chocolate- heat up hazelnut or soy milk
add carob powder & maple syrup
Case Study- MC


Follow up #1:

Avoided all yellow and red MRT foods for 1 week, followed by…

LEAP phase 1 for 2 weeks

Lost 6.6lb without limiting food quantity or exercising

Follow up SS total= 33 (Initial SS= 69, improved by 36 points in 3 weeks)
Follow up #2:

Started probiotic (boost immune health) and curcumin (anti-inflammatory
for joint pain)

LEAP phases 2-5 for 1 month

Lost 1 additional pound

Follow up #2 SS= 21 (improved by 12 additional points in 4 weeks, 48 total points)

Added in additional anti-inflammatory compounds: omega 3 fish oil, OPC-Sorb
(antioxidant blend for pain)
My Own Testimonial
R-arm, eczema flare up
R-arm, after following LEAP
elimination for 1 month
Conclusion

Inflammation, adverse food reactions, and chronic
disease are interrelated and may be present in your
patients.

By understanding various types of AFRs you will be able
to better identify problematic foods and provide the
appropriate dietary intervention.

Primum non nocere- first do no harm.
 Short-term
elimination diets are typically not harmful
and may potentially change someone’s life!
 Help
your patients to heal from the inside out,
supporting them through every step of the process.
References
1.
Food Allergy: Adverse Reactions to Foods and Food Additives, Fifth Edition. Edited
by Dean D Metcalfe, Hugh A Sampson, Ronald A Simon and Gideon Lack. 2014
John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
2.
Castro-Sanchez, P. & Martin-Villa, J.M. (2013). Gut immune system and oral
tolerance. British Journal of Nutrition, 109, pp. S3-S11.
3.
MacDonald T.T. & Monteleone G. (2005). Immunity, Inflammation, and Allergy in the
Gut. Science, 307(5717), pp. 1920-1925.
4.
Lied, GA. Indication of immune activation in patients with perceived food
hypersensitivity. (2014). Dig Dis Sci, 59(2), 259-266.
5.
LILLESTØL K, HELGELAND L, BERSTAD A, et al. Indications of ‘atopic bowel’ in patients
with self-reported food hypersensitivity. Alimentary Pharmacology &
Therapeutics [serial online]. May 15, 2010;31(10):1112-1122. Available from:
Academic Search Premier, Ipswich, MA. Accessed March 18, 2015.
6.
Thierry Piche, Giovanni Barbara, Philippe Aubert, Stanislas Bruley Des Varannes,
Raffaella Dainese, et al. Impaired intestinal barrier integrity in the colon of patients
with irritable bowel syndrome: involvement of soluble mediators.. Gut, BMJ
Publishing Group, 2009, 58 (2), pp.196-201.
7.
Pasula, Mark J.; The Patented Mediator Release Test (MRT); A Comprehensive Blood
Test for Inflammation Caused by Food and Food-Chemical Sensitivities. Townsend
Letter, January 2014
Thank you!
Erin Peisach, RDN, CLT
Nutrition by Erin, LLC
1777 Reisterstown Road, suite 118A
Pikesville, MD 21208
410-635-4210
[email protected]
www.nutritionbyerin.com
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