Allergic Disease - Food-Dependent Exercise-Induced Anaphylaxis Practice Guidance Toolkit 

Last Updated: 2016-04-21

Description and Key Nutrition Issues

Description
Exercise-induced anaphylaxis (EIA) has been defined as “the onset of allergic symptoms during, or
immediately after, exercise, the clinical signs being various degrees of urticaria, angioedema, respiratory
and gastrointestinal signs and even anaphylactic shock” (1). Sensitivity to a specific food as
a predisposing factor of EIA has been defined as food-dependant EIA (FDEIA) (2). A number of foods are
associated with FDEIA, but the most common food implicated worldwide is wheat (3). Since wheat is
such a common component of the diet, wheat-dependant EIA (WDEIA) is therefore an important
differential diagnosis to consider in the absence of any obvious reported trigger (3). Unlike other types of
food allergy, in order for symptoms to occur, there has to be a form of exercise undertaken in close
proximity to the consumption of the trigger food (4,5). Jogging is the most common exercise to provoke
the reaction, but other activities such as dancing, cycling and walking have been implicated.

See Additional Content: Food Allergies - Food-Dependent Exercise-Induced Anaphylaxis Background.

Key Nutrition Issues

This toolkit discusses the following key nutrition issues:
Š foods implicated in FDEIA
Š types of exercise that can trigger FDEIA.

Nutrition Assessment

The nutrition assessment of an individual with food-dependent exercise-induced anaphylaxis (FDEIA) may
include the following parameters using NCP terminology:

Anthropometric Measurements

Š Height/Length
Š Weight
Š Weight Change
Š BMI
Š Body Compartment Estimates (waist circumference)
Š Growth Pattern Indices/Percentile Ranks

Anthropometric Comparative Standards – Adult

Measure NCP Terminology

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 Š Weight and Growth Recommendation
Adult BMI » Recommended body weight/BMI
Š Ideal/reference body weight (IBW)
Š Recommended BMI

Waist As above
Circumference

Anthropometric Comparative Standards – Children

Measure Recommendation NCP Terminology

Birth to 24 WHO Child Growth Š Weight and Growth

months Standards/Reference: Recommendation
Length-for-age For Birth to 5 years » Recommended body
Weight-for-age For 5 to 19 years weight/BMI/growth
Weight-for-length ΠDesired growth
Head pattern
Circumference
2 to 19 years of Growth Charts (WHO and
age CDC)
Height-for-age
Weight-for-age
BMI-for-age

Child BMI WHO Growth Charts Adapted

for Canada

UK-WHO 0-4 years

UK Growth 2-18 years

Food/Nutrition-related History

Š Food and Nutrient Intake

» Food and beverage intake
» Food intake
ΠAmount of food
ΠTypes of food/meals (e.g. wheat, tomato, cheese, celery, strawberry, peach,
milk, tree nuts, crustaceans, peanuts)

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 » Bioactive substance intake
ΠAlcohol intake
Š Medication and Complementary/Alternative Medicine Use
» Medications
ΠPrescription medication use (e.g. NSAIDs)
ΠOTC medication use (e.g. aspirin, NSAIDs)
Š Physical Activity and Function
» Physical activity (e.g. physical activity history, consistency, frequency, duration,
intensity, type)

Food/Nutrition-related Comparative Standards

Š Energy Needs
» Estimated energy needs
Š Macronutrient Needs
» Estimated fat needs
» Estimated protein needs
» Estimated carbohydrate needs
» Estimated fibre needs
Š Estimated Fluid Needs
Š Micronutrient Needs
» Estimated vitamin needs
» Estimated mineral needs
See International Dietary Reference Values Collection.

Nutrition-focused Physical Findings

Š Skin (e.g. hives, pruritus)

Š Digestive System (e.g. vomiting and diarrhea)
Š Vital Signs (e.g. hypotension, airway obstruction)
Š Other (e.g. angioedema, bronchial constriction, vascular collapse)

Biochemical Data, Medical Tests and Procedures

Š IgE (food-specific)
Š Skin Prick Tests
Š Oral Food Challenge
Š ω gliadin

Client History

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 Š Personal History
» Personal data
ΠAge
Š Patient/Client/Family Medical/Health History
» Patient/client or family nutrition-oriented medical/health history (atopy, history of
FDEIA)

Professional Tools and Calculators

Adult BMI Calculator

Child BMI Calculator
International Dietary Reference Values Collection
International Dietary Guidelines Collection
Waist Circumference Measurement
WHO Child Growth Standards for Birth to 5 years
WHO Growth Reference for 5 to 19 years

Growth Charts (WHO and CDC)

WHO Growth Charts Adapted for Canada

UK-WHO 0-4 years

UK Growth 2-18 years

Nutrition Diagnosis

Sample PES Statements (problem, etiology, signs and symptoms using some NCP terminology)
This statement is provided as an example only, and will not apply to all individuals:
Š Intake of unsafe food related to ingesting wheat an hour before running a marathon, as evidenced
by anaphylactic reaction.

Nutrition Intervention

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Nutrition Prescription
A nutrition prescription is often developed at the beginning of the nutrition intervention step. The nutrition
prescription is comprised of recommendations for the intake of nutrients or foods that are specific to the
individual. The recommendations are based on reference standards (e.g. Dietary Reference Intakes,
dietary guidelines and standards for specific health conditions), and the individual’s nutrition diagnosis(es).

The nutrition prescription communicates the recommendations that the dietitian and the client develop,
after completing the nutrition assessment and developing the nutrition diagnosis(es). It can also be used
as a comparative standard during the nutrition care process, such as, during the assessment, and
monitoring and evaluations steps.

Nutrition Prescription Examples

Recommend:
Š Modified Diet
» Food intake (e.g. wheat-free).
NCP Terminology for Nutrition Intervention
Nutrition interventions are likely to be in the area of nutrition education.

Nutrition Education Example(s)

Š Nutrition Education - Content
» Purpose of the nutrition education
» Nutrition relationship to health/disease
» Recommended modifications (e.g. avoid wheat, replacing it with other grains)
Š Nutrition Education – Application
» Skill development (e.g. keeping accurate food records in relation to physical activities)

Goals

Goals for an individual with food-dependent exercise-induced anaphylaxis (FDEIA) should be determined in
conjunction with the client, and should be specific to the individual. Goals that are set should be time-
sensitive, easily measured, and achievable by the nutrition intervention. Both short-term and long-term
goals may be set. Examples of short- and long-term goals include:
Š to identify food and exercise triggers of FDEIA
Š to avoid exercise when food triggers of FDEIA are consumed.

Key Findings and Recommendations

Key findings and recommendations include:

Š foods implicated in food-dependent exercise-induced anaphylaxis (FDEIA)
Š types of exercise that can trigger in FDEIA.

Issues Key Findings and Recommendations

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Food Triggers for FDEIA Food Triggers – Wheat
A number of foods are involved in FDEIA, but case series
reports and reviews suggest wheat may be one of the most
common foods implicated. Some of the allergens responsible
for triggering cases of wheat-dependent exercise-induced
anaphylaxis (WDEIA) have been identified in the gluten protein
fraction of the grain.

Although the most common route of exposure to wheat is

ingestion, the use of wheat-based soaps has also been linked
to WDEIA. The wheat protein most often associated with
wheat allergy, omega-5-gliadin (ω-5 gliadin), appears to also
be a significant allergen in WDEIA. A positive specific IgE
blood test result to ω-5 gliadin is a useful indicator of the
condition, particularly when the link to wheat as the culprit
food is not clear, or when the reaction has been labelled as
‘idiopathic’.

Other Food Triggers

Other foods besides wheat are important triggers of FDEIA.
Based on the evidence provided, the most common foods
involved may vary from study to study and possibly from
country to country.

There have been many case reports of particular foods, but

studies suggest that apart from wheat, shellfish and tomatoes
are frequently cited as foods involved in FDEIA.

Most recently foods known to contain lipid transfer proteins

(LTP) have been shown to contribute to FDEIA, which might
explain the involvement of foods such as tomatoes, peaches
and strawberries.

Presenting Symptoms
The presenting symptoms of FDEIA do not always involve
anaphylaxis. Individuals with FDEIA can experience
generalized pruritus, urticaria and angioedema, in addition to
symptoms more usually associated with or preceding
anaphylaxis such as acute gastrointestinal symptoms, upper
respiratory obstruction, tachycardia, hypotension and loss of
consciousness.

However, cardiovascular symptoms can be the sole

manifestation of exercise-induced food allergies, in which case
death can mimic sudden cardiac arrest due to other

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 pathologies.

Other Factors (Besides Exercise) That Can Trigger

Symptoms
The unpredictability and variability of attacks of FDEIA suggest
that in some individuals other variables, both immune and non-
immune, are necessary for the priming of the release of
mediators that are responsible for symptoms.

In addition to exercise, several studies have demonstrated that

aspirin/NSAIDs can exacerbate the condition, and that other
co-factors such as the consumption of alcohol, or the
simultaneous ingestion of more than one allergenic food or
food additive is required to trigger FDEIA.

Hormonal change during the premenstrual or ovulatory phase

of a woman’s menstrual cycle has been suggested to be
a contributory factor for the development of FDEIA in some
women.

Diagnosis of FDEIA
The diagnosis of exercise-induced anaphylaxis is one of the
most difficult in allergy practice.

Challenge with the suspect food without exercise is often

negative, and in some cases any suspicion of food allergy had
not been evident prior to the event itself.

The offending allergen is often determined only after several

anaphylactic episodes, once a consistent pattern has
emerged.

Skin and blood tests for allergen-specific IgE are usually

positive for the offending food. However, the food is usually
well-tolerated in the absence of exercise.

Testing for the wheat allergen omega-5 gliadin (ω-5 gliadin),

the peach lipid transfer protein (LTP) allergen Pru p 3 and
tropomyosin allergens in shellfish, either individually or
collectively using a microarray, are all useful if FDEIA is
suspected but the history is poor or inconclusive.

Variables that provoke symptoms in different subjects include

the type and possibly quantity of food ingested, the degree of
exercise undertaken, alcohol consumption, and the intake of

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© Dietitians of Canada. 2021. All rights reserved.
 aspirin and possibly other medications.

Exercise Triggers for FDEIA The first case report on FDEIA, published in 1979, involved
a long distance runner who only experienced anaphylaxis
when exercising if he had consumed shellfish.

Although linked to strenuous exercise such as running and

swimming, it has been reported that a variety of types of
exercise can be involved including football, gymnastics,
volleyball, basketball, tennis, badminton and aerobics.

However, lower levels of exertion such as table tennis, horse-

riding, dancing, playing golf, raking leaves and even walking
have all been reported to trigger FDEIA.

Nutrition Monitoring and Evaluation

Indicators that may be monitored during the nutrition monitoring and evaluation step include:

Possible NCP Terminology

Indicators to
Monitor

Changes in Body Anthropometric Measurements – Adult

Weight
Š Height
Š Body Weight
Š Weight Change (% weight change over one month, three months, six
months)
Š Adult BMI
Š Compartment Estimates (waist circumference)
Š Comparative Standards
» Ideal/reference body weight
» Recommended BMI

Anthropometric Measurements – Child

Š Height/Length
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© Dietitians of Canada. 2021. All rights reserved.
 Š Body Weight
Š Comparative Standards
» Child BMI
» Desired growth pattern
ΠWHO Child Growth Standards
ΠWHO Growth Reference 5-19 years
ΠAustralian Growth Charts (WHO & CDC)
ΠWHO Growth Charts Adapted for Canada
ΠUK-WHO 0-4 years
ΠUK Growth 2-18 years

Changes in Food/Nutrition-Related History

Dietary Intake
Š Food and Nutrient Intake
» Food and beverage intake
ΠFood intake
ΠAmount of food
ΠTypes of food/meals (e.g. wheat, tomato, cheese,
celery, strawberry, peach, milk, tree nuts,
crustaceans, peanuts)
» Bioactive substance intake
ΠAlcohol intake
Š Medication and Complementary/Alternative Medicine Use
» Medications
ΠPrescription medication use (e.g. NSAIDs)
ΠOTC medication use (e.g. aspirin, NSAIDs)
Š Physical Activity and Function
» Physical activity (e.g. physical activity history, consistency,
frequency, duration, intensity, type)

Recent Changes Client History

in Client History
Š Patient/Client Family Medical/Health History
» Patient/client or family nutrition-oriented medical/health history
(changes in incidence of FDEIA)

Nutrition Education Materials

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© Dietitians of Canada. 2021. All rights reserved.
Key Additional Client Handouts

The following key client handouts were developed by third-parties external to PEN® and its partner
organizations. Other tools and resources for professionals and clients can be found under the Related
Tools & Resources tab.

Title: Wheat – One of the Ten Priority Food Allergies

English French

Additional Information

Clinical Practice Guidelines

Title: Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the
NIAID-sponsored Expert Panel Report

Nutrition Care Process Terminology

See country-specific information on NCPT in Nutrition Care Process and Terminology Web Links

See Additional Content: Nutrition Care Process and Terminology Background.Nutrition Care Process and
Terminology Web Links

References

1. Castells MC, Horan RF, Sheffer AL. Exercise-induced anaphylaxis. Curr Allergy Asthma Rep.
2003;3(1):15-21. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/12542988
2. Kidd JM 3rd, Cohen SH, Sosman AJ, Fink JN. Food-dependent exercise-induced
anaphylaxis. J Allergy Clin Immunol. 1983;7194):407-11. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/6833679
3. Hompes S, Dölle S, Grünhagen J, Grabenhenrich L, Worm M. Elicitors and co-factors in food-
induced anaphylaxis in adults. Clin Transl Allergy. 2013;3(1):38. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/24262093

4. Romano A, Di Fonso M, Giuffreda F, Quaratino D, Papa G, Palmieri, et al. Diagnostic work-

up for food-dependent, exercise-induced anaphylaxis. Allergy. 1995;50(10):817-24. Abstract
available from: https://www.ncbi.nlm.nih.gov/pubmed/8607564
5. Shadick NA, Liang MH, Partridge AJ, Bingham C, Wright E, Fossel AH, et al. The natural
history of exercise-induced anaphylaxis: survey results from a 10-year follow-up study. J

Allergic Disease - Food-Dependent Exercise-Induced Anaphylaxis Practice Guidance Toolkit 10

© Dietitians of Canada. 2021. All rights reserved.
 Allergy Clin Immunol. 1999 Jul;104(1):123-7. Abstract available from:
https://www.ncbi.nlm.nih.gov/pubmed/10400849
This toolkit provides an overview of practice recommendations and other relevant information contained in
Practice Questions and Backgrounds in PEN® Knowledge Pathways. To view the key practice points and
other relevant information (including the associated references) see the Food Allergies - Food-Dependent
Exercise-Induced Anaphylaxis Knowledge Pathway.

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