Food Allergies, Food Intolerance, and Skin Disorders

I. Definition
1. Allergy an adverse reaction following exposure to an inhaled, ingested, or injected substance that results
in a response from the immune system
a. Asymptomatic allergy a person who produces antibodies without having any symptoms
b. Symptomatic allergy a person who produces antibodies and has symptoms

2. Food allergy an adverse food reaction that is mediated by an immunoglobulin E (IgE) immunologic
mechanism; induced by cell-mediated or immune-complex disease; the reaction occurs consistently after
ingestion, inhalation, or touch of a particular food causing functional changes in target organs
-an immune response, generally from IgE, which usually occurs within 2 hours. A food allergy results from
hypersensitivity to an antigen of food source (usually protein). The manifestations of the allergy are caused
by the release of histamine and serotonin. The most common results (70%) of food allergies are
gastrointestinal: diarrhea, nausea, comiting, cramoing, abdominal distention and pain; 24% are skin related,
4% are respiratory, and 2% involve other systemic responses

3. Food intolerance
*an adverse reaction to a food caused by toxic, pharmacologic, metabolic, or idiosyncratic reaction to the
foods or chemical substances in the food
*a physiologic response to an ingested food or food additive that is not proved to be immunologic in nature.
This category includes idiosyncratic, pharmacologic, metabolic, or toxic food reactions

4. Food idiosyncrasy a quantitatively abnormal response to a food or food additive. Such response differs it
physiologic or pharmacologic effect and resembles a hypersensitivity reaction, but there is no immune
mechanism

5. Immune system all organs, cells, and molecules that respond (both positively and negatively) to
environmental substances

6. Immunoglobulin E (IgE)-mediated reaction rapid onset of symptoms occurring after ingestion of a specific
allergen that cross-links the antigen-specific IgE molecule to mast cells and basophils

7. Pharmacologic food reaction a reaction to chemicals, including food additives, ingested food

8. Antigens usually a foreign substance (e.g. protein, cells, bacteria, polysaccharides) that stimulates
antibody production

9. Allergen substance foreign to the body that on interaction with the immune system, causes an allergic
reaction

10. Mast cells tissue cells that release histamine or other substances causing allergic symptoms

II. Objectives of Dietary Management
1. Exclude or avoid the offending allergen. If it is not known, use the Rowe elimination diet to discover cause.
2. Monitor the onset of the reaction, which may be delayed or immediate, If delayed, the onset of the reaction
may take as long as 5 days. An immediate response is more common with raw foods; patient history may
include diarrhea, urticarial, eczema, rhinitis, and asthma. Cooking may alleviate some allergic properties,
but this is not guaranteed.
3. Treat nutritional deficiencies or ensure adequate supplementation
4. For patients with asthma, use a normal diet with small meals. Nothing should be given after dinner, to
reduce GI reflux.
5. Keep food diaries to determine food reactions.
6. Ensure intensive nutritional counseling when allergies are complex to avoid nutrient deficiencies and
unnecessary restrictions

III. Immunologic Basis for Allergic Reactions
There are many adverse reactions to the ingestion of food including allergic, idiosyncratic, toxic, metabolic,
and pharmacologic reactions. Food allergy can be distinguished from other types of adverse reactions to
food by the following features:
a. It is mediated by an immunologic mechanism
b. It can be consistently reproduced by a blinded food challenge
c. It causes functional changes in the target organ

IV. The Immune System
Function: it clears the body of foreign substances or antigens (e.g. viruses, bacteria, blood cells, and tissue
cells)
The immune system consists of the bone marrow, bursal-equivalent tissue, thymus, spleen, lymph nodes,
tonsils, gut-associated lymphoid tissues (Peyers patches) and bronchial-associated lymphoid tissue (Lusters
patches).

3 type of cells that respond to antigens:
1. B lymphocytes these produce antigen-specific antibodies in response to an antigen
2. T lymphocytes these do not produce antibodies but recognize antigens
3. Macrophages these are derived from monocytes in the blood; through phagocytosis, the macrophage
engulfs and destroys antigens

2 branches of the immune system:
1. Cellular or cell-meditated pathway
This involves the actions of T lymphocytes (T cells) produced by the thymus. The T cells produce
lymphokines and cytokines (substances that regulate the activity of the B cells) causing direct cellular
damage to target cells and destroying the antigens. T cells generally protect against tumors and help or
suppress immunoglobulin production. The cells may play a role in gluten-sensitive enteropathy.

2. Humoral mediated responses
Humoral immunity involves antibodies (immunoglobulins) which have an important role in food
allergy. The B cells are produced by bursal-equivalent tissue. In response to an antigen, B cells produce
the immunoglobulins (antibodies) IgA, IgD, IgE, IgG, and IgM that bind the antigens. This leads to
neutralization, osponization, complement activation, phagocytosis, or hypersentivitiy reactions. IgD, IgG,
and IgM protect against bacteria. IgA in the saliva and intestinal secretions prevents absorption of
macromolecules. IgE attacks parasites and is the immunoglobulin responsible for the classic allergic
reaction.

The thymus and tonsils have a role in immunity
*The thymus (a ductless, glandlike organ that produces T cells) is important in the development of
peripheral lymphoid tissue
*The tonsils (two small, rounded masses of lymphoid tissue found along the path of inspired air and
ingested food and liquid) trap foreign materials inspired into the airways in the tonsillar crypts that come into
contact with antigen-processing cells

Types of allergic reactions
Reaction/Classification Mechanism Comments
Type I: immediate
hypersensitivity,
Allergen binds with sensitized IgE antibody
on mast cells (specialized granular cells in
Applies to hay fever, anaphylaxis, most food
allergies, atopic dermatitis, asthma. Symptoms
Reaction/Classification Mechanism Comments
anaphylactic the intestines, skin, and respiratory tract) or
basophils (similar to the cells in blood). This
results in the release of mediators
(histamine, eosinophilic chemotactic factor,
bradykinin, etc.) IgG has also been identified
as being involved in this reaction.
occur within seconds to up to 2 hours.
Symptoms of food reactions may include
laryngeal edema, nausea, vomiting, severe
abdominal pain, bloating, diarrhea, andio-
edema, eczema, erythema, itching, hoarseness,
wheezing, cough, chest tightness, hypotension,
broncho-spasms, and shock
Type II: cytotoxic IgG antibody reacts with cell membrane or
an antigen associated with the cell
membrane
Results from transfusion of incompatible blood
types.
No food reactions have been demonstrated
Type III: Antigen-
antibody complex Anthus
reaction
Antigen and antibodies (IgG and IgM) form a
complex called precipitating antibody. The
antigen-antibody complex is known as
Arthus reaction when it occurs in soft
tissues, like blood vessels, lungs, or kidneys
and as serum sickness when the complex
circulates. Complement is also activated in
some cases.
Occurs in some food reactions. Milk precipitins
have been found in the lungs of some children
with chronic respiratory infection and in the GI
tract of those with gastro-enteropathy.
Reactions usually take 6 hours or more to
appear and may take several days to be
clinically apparent
Type IV: delayed or cell-
mediated hypersensitivity
T cells interact directly with antigen Usual mechanism of graft rejection. Possible
involved in some food allergies, such as protein
losing enteropathies

V. Pathogenesis of Food Sensitivity
Type I IgE mediated reactions occur most frequently. Sensitized IgE binds to mast cells, specialized granular
cells, in the respiratory tract, skin and intestines. An allergic reaction occurs when an allergen bridges two
molecules of sensitized IgE, causing the cell to release chemical mediators (including histamine) and the cell
membrane to release phospholipids. The mediators cause itching, contraction of smooth muscles, dilation of
small blood vessels, secretion of mucus, and attraction of eosinophils to the area.

VI. Common Food Allergens
1. Foods most commonly reported to cause allergic reations in the pediatric population are cows milk,
chicken eggs, legumes (peanuts and soybeans), wheat, tree nuts (filberts and cashews), and fish. Studies
in adults are limited, but they indicate that shellfish, peanuts, nuts and grains frequently cause reactions.

2. Cross-reactivity may occur between different foods especially between foods in the same biological family.
For example, patients allergic to soybeans are often allergic to other legumes.

3. Allergens are usually acidic proteins or glycoproteins. Antigenic activity is believed to reside in a specific
series of amino acids that binds with the IgE antibody. The amino acids may be sequential or linear in the
protein molecule, or they may be brought into correct sequence by folding of the protein molecule.

Most common allergens and nutritional consequences
Milk Check for deficiencies in protein, riboflavin, vitamin A,
vitamin D, and calcium. Be wary of introduction of cows milk
in infancy
Eggs Check for iron deficiency. Egg albumin is used in
marshmallows, frozen dinners, and many other food mixes.
Yolks are generally tolerated
Wheat Check for B vitamins and iron. Read labels on packaged
soups, sauces
Fish Soiled sources, even before taste change occurs, are
especially high in histamine
Shellfish (crab, lobster, shrimp) Severe reactions may occur
Tomatoes Usually an allergenic reaction to tomatoes is linked to the
frequency of use in the diet
Citrus fruits Person allergic to citrus fruits can easily become deficient in
vitamin C. A supplemental source may be needed
Cola, chocolate These are easily identified in foods
Legumes (peanuts, soybeans, peas, lima beans) Watch labels for lecithin and other soy additives
Corn Hidden sources of corn include cornstarch, corn syrup, corn
oil, frozen yogurt, baking powder, paper plates, etc
Nuts Avoid nut butters also. Aflatoxin can cause reaction
Spices Cinnamon is a common allergen
Artificial food dyes It may be necessary to eliminate aspirin and salicylates.
Many drugs contain tartrazine (FD&C no. 5 yellow dye).
Molds This category include penicillin. Use a diet low in milk and
milk products (watch out for deficiencies in calcium and
riboflavin), mushrooms, cheese, sour cream, bacon, jams,
and jellies, spices and sausages
Sulfites Foods from sald bars, wine, beers, colas, dried fruits and
vegetables, maraschino cherries, dried or frozen potatoes
may contain sulfites

VII. Food Allergy Symptoms
Symptoms of IgE-mediated food allergy can occur within seconds or up to 2 hours after eating a food
(immediate reaction). In immediate hypersensitivity reactions, symptoms may not occur for several hours while
delayed reactions occur 2 to 48 hours after.

The common results (70%) of food allergies are gastrointestinal; 25% of results are skin-related, 4% are
respiratory, and 2% involve other systemic responses.

Symptoms of Food Allergies
Gastrointestinal Manifestations
Abdominal pain
Nausea
Vomiting
Diarrhea
GI bleeding
Protein-losing enteropathy
Oral and pharyngeal pruritus
Cutaneous Manifestations
Urticaria (hives)
Angioedema
Eczema
Erythema (skin inflammation)
Itching
Flushing
Respiratory Manifestations
Rhinitis
Asthma
Cough
Laryngeal edema
Milk-induced syndrome with respiratory disease
(Heiners syndrome)
Airway tightening
Systemic Manifestations
Anaphylaxis
Hypotension
Dysrhythmias
Controversial or Unproven Manifestations
Behavioral disorders
Tension-fatigue syndrome
Controversial or Unproven Manifestations
Attention-deficit and hyperactivity disorder (ADHD)
Otitis media
Psychiatric disorders
Neurologic disorders Neurologic disorders
Musculoskeletal disorders
Migraine headaches

VIII. Diagnosis of Food Allergy
In no instance do the results of a single test determine a conclusive diagnosis of food allergy. Its
diagnosis is based on accumulated evidence that includes the history, physical examination, appropriate
immunological and other tests, trial elimination diet, and food challenge.

Food Allergy Assessments
Aspect Description
History *provides a detailed description of symptoms, time from time of ingestion of food
to onset of symptoms, most recent reaction, and quantity of food necessary to
produce a reaction, and suspected foods
*includes family history of allergic disease, enzyme deficiencies and so forth
Physical examination *includes anthropometric evaluation, assessment of growth and development and
nutritional status
*assesses other chronic diseases
*evaluates allergic conditions like allergic rhinitis, eczema, and asthma
Food and symptoms diary for 2 weeks *provides actual record of food, amount and time when eaten, time of appearance
of symptoms and any medication taken
*allows assessment of dietary adequacy
Immunological testing (skin tests,
RAST, others)
*yields of suspect foods
*requires confirmation of positive results by trial elimination diet and food
challenge to show clinical sensitivity to food
Trial elimination diet for 2-4 weeks or
until symptoms clear
*needs to be nutritionally sound
*required that patient record all ingested food as the suspect food may be
ingested in an alternative form
*begins with a simple elimination diet; only foods suspected by history, food diary,
and/or immunological testing are eliminated
*progress to more extensive elimination diet if symptoms do not clear on simple
diet. Only one food in each food group or exotic foods never eaten before are
allowed
*may require use of hypoallergenic diet if symptoms do not clear on an extensive
elimination diet
Food challenge *excludes foods known to cause severe reactions such as wheezing, asthma, or
anaphylaxis
*return suspect foods to diet one at a time after symptoms have cleared for 2 4
weeks. The amount is increased until it approximates usual intake.
*is repeated following positive reactions as coincident reactions are common
*performed as double-blind challenge when uncertainty about reaction persists

Diagnosis of Food Sensitivity
Reliable Tests
Oral Challenge The patient is on a hypoallergenic diet and given a test dose
of suspected food in capsule form and response is
measured. The test may be open, blind, or double blind.
Skin Testing Dilute extract of food is placed on scratched or punctured
skin. This test is more accurate for nonfood allergies (pollen,
etc.) and needs follow up by oral challenge as there are
many false positives for food allergies
ELISA (Enzyme-Linked Immuno-sorbent Assay) This test is similar to RAST but does not use a radioactive
substance. It is also less expensive.
Unreliable Tests
Cytotoxic Testing (Leukocyte Antigen Testing, Brians Test) White blood cells are mixed with plasma and examined
under a microscope with exposure to a food sample
Neutralization Testing (Provocative Testing) Food extract is injected under the skin to cause symptoms,
which are followed by more injections to neutralize
symptoms
Sublingual Testing Drops of food are placed under the tongue and symptoms
are recorded

Food Intolerance
*a non-immune reaction to food or food additives
*its symptoms include gastrointestinal, cutaneous, and respiratory disorders often similar to food allergy

Food additives (preservatives, flavor enhancers, coloring agents)
1. Aspartame a nutritive artificial sweetener
*WHO and FDA maximum level of acceptable intake is 40-50mg/kg BW
*Symptoms: headache, rash, leg nodules

2. Benzoates and Parabens extreme reactions rare
a. Benzoic acid (sodium benzoate) most common antimicrobial food additive or preservative in
carbonated and non-carbonated beverages, syrups, fruit salads, icings, jams, jellies, preserves, salted
margarine, minced meat, pickles and relishes, sauerkraut, pie and pastry fillings, and cider

b. Parabens preservatives and antimicrobial agents
*later stages of paraben metabolism mimic the metabolism of benzoates
*terms of food labels include methyl p-hydroxybenzoate or propyl p-hydroxybenzoate
*added to processed vegetables, baked goods, fats and oils, and seasonings, cakes, pie crusts,
pastries, icings, toppings and fillings (fruit jellies and creams), ciders, carbonated beverages and beer,
fruit products (sauces, juices, salads, syrups, fillings, preserves and jellies), sucrose syrup, olives, and
pickles

3. Butylated hydroxyanisole (BHA) and butylated hydroxytoluene (BHT) antioxidants used to inhibit fat oxidation
*used in vegetable oild and shortenings for deep-fat frying; found in high fat foods such as potato chips,
nut meats, doughnuts, pastries and pie crusts; dehydrated potatoes, dried fruits, breakfast cereals and
cake mixes; terpene-like flavoring, oils (orange, lemon), chewing gum, candy, and yeast
*Symptoms: chronic urticarial

4. Mold
*symptoms: when ihaled, include allergic rhinitis (sneezing, running nose, congestion and itchy eye and
nose); wheezing; difficulty of breathing
*Avoid mushrooms, cheese, sour cream, buttermilk, bacon, sausage, and ham

5. Monosodium Glutamate (MSG) widely used food additive and flavor-enhancer to canned, packaged and
prepared foods, commercial spice mixtures, bouillon cubes, hydrolyzed protein
*Symptoms: Chinese Restaurant Syndrome; headache, tightness of chest, stiffness and/or
generalized weakness of the limbs, light-headedness, facial flushing, profuse sweating,heartburn,
gastric discomfort, and burning sensation at the back of the neck

6. Nickel or nickel salts
*Symptoms: dermatitis, eczema
*Foods to avoid in a nickel-restricted diet
1. Meat: shellfish (shrimp and mussels)
2. Vegetables: beans (green, brown, white), sprouts, kale, leeks, lettuce, peas, spinach
3. Fruits: figs, pineapple, prunes, raspberries
4. Grains: buckwheat, millet, oatmeal, wheat bran products, multigrain bread
5. Drinks: chocolate and cocoa drinks, tea from dispensers

7. Nitrates and nitrites commonly used preservatives and known for their flavoring and coloring attributes
*Symptoms: vascular headaches, associated with increased incidence of certain cancers
*Avoid: cured or processed meats such as ham, bacon, salami; listed on the ingredient label as sodium
nitrite or potassium nitrite

8. Penicillin
*Symptoms: some types of chronic urticarial or allergies attributable to penicillin
*Avoid: milk and all dairy products, cheese and cheese products, cream and cream products, milk
solids, casein, lactalbumin, curds, whey since they may conain penicillin as a contaminant

9. Sulfites and sulfating agents used to prevent browning, modify dough texture, control microbial growth, and
certain bleaching foods
*Symptoms: bronchospasms (asthmatics); reported but not proven symptoms include flushing, hives,
GI disturbance, anaphylactic shock

Foods to avoid:
1. Bakery products: cookies, crackers, pie crusts, pizza crusts, quiche crusts, flour tortillas, all bakery
products with dried fruits and vegetables
2. Beverage: beer, cocktail mixes, dried citrus fruit, beverage mixes, wine, wine coolers
3. Dairy products: filled milk (skim milk enriched in fat content with vegetable oil)
4. Fish and shellfish: canned clams; dried cod; fresh, frozen, canned and dried shrimp, frozen lobster,
scallops
5. Fruits: processed fruits including canned, bottled or frozen fruit juices; dried fruit; canned, bottled, or
frozen diuretic fruit or fruit juices, maraschino cherries, glazed fruits
6. Vegetables: fresh, pre-cut potatoes
7. Others: condiments and relishes (horseradish, onion and pickle relish, pickles, olives, salad dressing
mixes, wine vinegar)
8. Sweets: confections and frosting containing brown, raw, powdered or white sugar derived from sugar
beets

10. Tartrazine and Acetylsalicylic Acid
*Tartrazine (FD and C yellow No. 5) coloring dye used in foods, drugs, and cosmetics
*Acetylsalicylic acid (aspirin): the only proven allergenic salicylate
*Symptoms: chronic urticarial, asthma

Carbohydrate intolerance the most common enzyme deficiency
*a deficiency of the intestinal enzyme lactase results in a decreased ability to digest lactose, the sugar in milk;
symptoms of abdominal cramping, flatulence, and diarrhea occur

Skin disorders
Psoriasis a serious, chronic, relapsing, skin ailment in which the involved skin areas produce silvery scales; areas usually
affected are the skin of the elbow, knees, back, buttocks and scalp

Treatment used are:
a. Medications such as anti-metabolites or systemic corticosteroids and methotrexate which as a folic acid antagonist;
it also causes malabsorption of vitamin B12, fat and carotene
b. Adequate diet as part of building up and maintaining good health; a taurine-restricted diet may be beneficial