Adverse Reactions to

Food
Clinical Nutrition
Chapter 26

Donna Plummer EdD RD

 Objectives
• At the end of the presentation students will be able to
• Describe a food allergy
• Explain the difference between a food intolerance and food allergy
• State appropriate interventions for persons with food allergies
 Background
• Every year food allergies cause about 30,000 visits to the emergency room
• It is estimated to cause ~150 deaths per year
• 90% is caused by 8 foods milk, eggs, peanuts, tree nuts, fish, shellfish.
Soybean and wheat (not celiac disease)
• May be caused by food additives (a small amount)
 Adverse Food Reaction
• Any negative response the ingested food or drink
• Food Intolerance
• Negative reactions to food which does not include an immune response
• Food Allergy
• Adverse health effect arising from an immune response that occurs on exposure to a
given food. This includes food, drink, food additives, dietary supplement
 Occurrence of food allergy
• Based on CDC data 50 million Americans have some kind of allergy
• Food allergy is estimated to affect 4-6% of children and 4 % of adults
• Most common in infants but can develop at any age
• Food allergy causes an immune system reaction that may affects
numerous organs in the body.
• Food intolerance symptoms are generally less serious and often limited to
digestive problems
 Allergic Reactions Among Children Under
3 years old
• May be related to GI tract development
• Cow’s milk
• > 80% become tolerant by their 5th birthday
• Egg allergy
• > 85% become tolerant by their 3rd birthday
• Peanut allergy
• Clinical tolerance reached in a small minority
 Epidemiology cont’d
• 65% of persons with allergies have a close relative with allergies
• Possible relationship with increased intestinal permeability as seen with
• Viral gastroenteritis
• Premature birth
• Leaky gut
 Etiology
• Increase in food allergies noted worldwide
• Early life factors
• Intestinal and skin barrier defects
• Microbiome
• Chronic stress
 Allergic immune response
• Antibodies immune proteins produced in response to an antigen or allergen.
• Referred to as immunoglobulins (Ig)
• T-cells produced by the bone marrow then transformed by the thymus gland. Also called lymphocytes
• T-cells stimulate beta cell to produce antibodies
• Antibodies attach to mass cells/granulocytes. Release histamines
• Mass cells located in lung, skin, tongue, lining of the nose and GI tract
• Also synthesize prostaglandins, leukotrienes and plasma activating factor.
• Causes vasodilation, increase vascular permeability, nerve activation, smooth muscle contraction, mucus secretion and
diarrhea
 Allergic Response
• Breakdown of oral tolerance
• The process that prevents an immune response to ingested antigens
• Controlled by dendritic cells, macrophages, and T-reg cells
• The gut microbiome supports T-reg cells
• Sensitization
• Increase cut permeability and intact protein reaching the GALT. Dysbiosis, GI disease,
malnutrition, fetal prematurity, immunodeficiency
• Reaction
 Immunoglobin E (IgE) mediated
reactions
• IgE is produced in response to the presence of allergen
• Attaches to the mass cells
• Release of histamines and inflammatory mediators
• Rapid onset
• Mild to life threatening
 Response of Immune System
• IgE Mediated
• Food trigger production IgE which binds to mass cells in the GI tract
• Food allergens (often a protein) penetrate mucosal barrier and trigger IgE
antibodies
• The antibodies bind to mass cells which release histamine
 Histamine
• In humans histamine is found in nearly all tissues of the body, where it is
stored primarily in the granules of tissue mast cells. The blood cells called
basophils also have histamine-containing granules.
• Histamine produces many effects within the body, including the
contraction of smooth muscle tissues of the lungs, uterus, and stomach;
the dilation of blood vessels, which increases permeability and lowers
blood pressure; the stimulation of gastric acid secretion in the stomach;
and the acceleration of heart rate.
 Histamine cont’d
• The effect histamine has on blood vessels is crucial to its role in the immune
response, which is most clearly observed in inflammation—i.e., the local reaction of
bodily tissues to injury caused by physical damage, infection, or allergic reaction.
• Injured tissue mast cells release histamine, causing the surrounding blood vessels to
dilate and increase in permeability. This allows fluid and cells of the immune system,
such as leukocytes (white blood cells) and blood plasma proteins, to leak from the
bloodstream through the vessel walls and migrate to the site of tissue injury or
infection, where they begin to fight the infection and nourish and heal the injured
tissues.
 Histamine cont’d 2
• In an allergic reaction—the immune system’s hypersensitivity reaction to
usually harmless foreign substances (called antigens in this context) mast
cells release histamine in inordinate amounts.
• Immune system proteins called antibodies, which are bound to mast cells,
bind to the antigens to remove them, but in the process the mast cells are
stimulated to release their histamines. This causes the visible symptoms of a
localized allergic reaction, including runny nose, watery eyes, constriction of
bronchi, and tissue swelling as well as anaphylactic reactions
 IgE mediated Symptoms
• Cutaneous
• Urticaria (hives), angioedema (welts), rashes, flushing
• Gastrointestinal
• Lip, tongue itching and swelling, laryngeal edema, vomiting and diarrhea
• Respiratory
• Itching and tearing, swelling of eyes, nasal congestion, bronchospasm, wheezing
• Generalized
• Anaphylactic shock
Common Food that results in IgE response

• Children • Adults
• Cow’s milk • Shellfish
• Peanuts • Peanut
• Wheat • Milk
• Soy • Tree nuts
• Eggs • finfish
 Pathophysiology
• GI tract forms a barrier to outside products
• GALT mount a response to pathogens
 Anaphylaxis reaction
• Acute, systemic/multiple organs, severe allergic reaction
• Symptoms
• Respiratory distress, abdominal pain, nausea, vomiting, cyanosis,
angioedema, shock, cardiac arrest, death
• Most common with peanut, tree nut, shellfish and fish.
 Non-IgE Mediated allergies
• Activation of cells other than IgE
• Eosinophils stimulate release of granules
• Response is usually more delayed
• Celiac disease
 Food dependent, exercise induced
• IgE reaction is triggered only when exercise occurs within 2-4 hours after
eating the food item.
• Occasionally the reaction occurs when the food is eaten before exercising
• Reaction does not occur without exercise
 Pollen food allergy syndrome
• IgE mediated reaction
• Response usually limited to the oropharyngeal cavity
• The food allergen protein is similar to protein in pollen (usually of birch,
ragweed, and other grasses)
• These proteins are altered by heat. Cook fruits and vegetable do not evoke
the response.
 Avoidance of Allergen
• Milk – Alternate sources of Vit A, D, protein and Ca
• Egg – Vit A, D, E selenium, iodine, protein
• Wheat – iron, thiamin, riboflavin, folate, fiber
• Fish/shellfish – protein, iodine, omega 3 fatty acids
• Peanut – vit e, niacin, Mg. protein
• Soy – B vitamins, P, Mg, Fe, Zn protein, fiber.
 Food Intolerance
• Adverse reaction that does not involve the immune system
• Lactose intolerance
• FODMAP – Fructo, Oligo, di and mono saccharides
• Gluten intolerance – non-celiac gluten intolerance
• Histamine – has high histamine level or stimulate histamine production
 FODMAP
• Food to avoid
• Fructose: Fruits (including apples, mangos, pears, watermelon), honey, high-fructose corn
syrup, agave
• Lactose: Dairy (milk from cows, goats, or sheep), custard, yogurt, ice cream
• Fructans: Rye and Wheat, asparagus, broccoli, cabbage, onions, garlic
• Galactans: Legumes, such as beans (including baked beans), lentils, chickpeas, and
soybeans
• Polyols: Sugar alcohols and fruits that have pits or seeds, such as apples, apricots, avocados,
cherries, figs, peaches, pears, or plums
 FODMAP
• Foods allowed
• Dairy: Almond milk, lactose-free milk, rice milk, coconut milk, lactose-free yogurt, and hard cheeses.
• Fruit: Bananas, blueberries, cantaloupe, grapefruit, honeydew, kiwi, lemon, lime, oranges, and
strawberries.
• Vegetables: Bamboo shoots, bean sprouts, bok choy, carrots, chives, cucumbers, eggplant, ginger,
lettuce, olives, parsnips, potatoes, spring onions, and turnips.
• Protein: Beef, pork, chicken, fish, eggs, and tofu.
• Nuts/seeds: (limit to 10-15 each) Almonds, macadamia nuts, peanuts, pine nuts, and walnuts.
• Grain: Oats, oat bran, rice bran, gluten-free pasta, quinoa, white rice, and corn flour.
 High histamine content
• Fermented foods such as sauerkraut, soy sauce, and kimchi
• Vinegar and vinegar-containing foods such as pickles, mayo, olives
• Dairy products such as yogurt, kefir, sour cream and aged cheese
• Dried fruit
• Vegetables such as avocados, eggplant, and spinach
• Processed or smoked meats and fish, hot dogs
• Shellfish
 Stimulate histamine production
• Alcohol
• Fruits such as banana, papaya, and citrus fruits
• Tomatoes
• Wheat germ
• Beans
• Chocolate
• Nuts, especially walnuts, cashews, and peanuts
• Food dyes and other additives
 Low histamine foods
• Fresh meat and fresh-caught fish
• Non-citrus fruits
• Eggs
• Gluten-free grains such as quinoa and wild rice
• Dairy substitutes such as coconut and almond milk
• Fresh vegetables except for tomato, avocado, spinach, and eggplant
• Cooking oils such as olive oil
 Lack of Enzyme DOA
• Diamine oxidase (DAO) produced by intestine and other glands
• Breaks down histamine
• Healthy fats and other nutrients including phosphorus, zinc, magnesium,
copper, iron and vitamin B12 may play a role in enhancing DAO activity
 Food Additives
• Salicylates, artificial food dyes, preservatives, nitrites, MSG
• Produce symptoms similar to food allergies by not immune mediated
 Diagnosis
• Skin prick test
• Serum antibody test
 Dietary Intervention
• Elimination diet
• Slow reintroduction with observation
• Top 8 food allergens must be included of food labels
• Milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, soybean
• Oral food challenge
 Prevention
• Limited microbial exposure • Timing and introduction of solids
• Route of infant delivery • Vitamin D
• Antibiotic use • Fatty acids
• Prebiotic and probiotic • Folate
• Allergen avoidance
• Breastfeeding vs infant formula
 Histamine Blockers
• Histamine works by binding to histamine receptors on the surface of cells.
There are four kinds of receptors, called H1, H2, H3, and H4. The activity
of histamine can be blocked by various chemical drugs called
antihistamines, which prevent the binding of histamine to these receptors.
• Conventional antihistamines used to treat allergies block H1 receptors and
thus are called H1 antagonists. H2 antagonists are those drugs, such as
cimetidine (Tagamet), that inhibit gastric acid secretion and are used to
help heal peptic ulcers.