Adverse Food Reactions & Inflammation

Understanding the Connection and Empowering Patients to Heal from the Inside Out

BY ERIN PEISACH, RDN, CLTOWNER 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 immune-mediated 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: • White Blood Cells:

• Mast cells, basophils, eosinophils, lymphocytes, neutrophils, monocytes, macrophages, T-cells, NK-cells

• Antibodies:

• IgE, IgG, IgM, IgA, IgD

• Complement System:

• C3, C4

• Platelets

• Chemical Mediators

• Histamine, prostaglandins, serotonin, cytokines, leukotrienes, etc.

My Kindergarten take on the topic

Immune System 101

Innate Involves barriersFirst line of defense

AdaptivePrevents

indiscriminate responses to harmless antigens

Long lasting defense

Gut Immunology

GI tract has two major roles:

Digestion and absorption of nutrients

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

Gastrointestinal:• Cyclic Vomiting

Syndrome• Functional Diarrhea• Irritable Bowel

Syndrome• Lymphocytic Colitis• Crohn’s Disease• Ulcerative Colitis• GERD• Celiac Disease• Systemic Lupus

Neurological:• Migraine• ADD/ADHD• Autism Spectrum

Disorder• Epilepsy• Depression• Insomnia• Multiple Sclerosis

Musculoskeletal:• Fibromyalgia• Rheumatoid Arthritis• Reactive Arthritis• Chronic Fatigue

Syndrome

Metabolic:• Metabolic

Syndrome• Obesity• Type 1 Diabetes• Type II Diabetes

Dermatological:• Atopic Dermatitis• Dermatitis

Herpetiformis• Urticaria• Psoriasis

Pulmonology• Asthma• Anaphylaxis

Urology• Interstitial

Cystitis

Endocrinology• Hashimoto’s• Grave’s Disease

Inflammation & Disease

Steps to Consider to Reduce Inflammation:

Identify inflammator

y triggers

Remove triggers

Heal the gut &

boost the immune system

Reduce

inflammation

Support

sustained

improvement in disease,

illness &

symptoms

Inflammatory Triggers Psychological

Stress, depression, anxiety

Environmental Mold, pollution, lack of outdoors/sunlight, allergens, toxin exposure

Lifestyle Choices Sedentary lifestyle, tobacco/drug/alcohol use, lack of sleep

Dietary choices 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

20

AFR

Toxic

Food Contaminant

Non Toxic

Immune mediated

Allergy

Sensitivity

Celiac

Non-immune mediated

Intolerance

Aversion

Adverse Food Reactions (AFR):

Non-Immunol

ogic Reaction

s

Enzyme Deficien

cies

Toxic Reaction

sMalabsorption

(FODMAPS)

Lectins

Histamine

Irritants

IMMUNE REACTIONS

ALLERGIES

TYPE 1

SENSITIVITIES

TYPE 3 TYPE 4

Food Allergy- Type 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

Oral Food Challenge The definitive, gold standard test

In vivo testing (SPT/Scratch test): skin 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, placebo-controlled) 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 Sensitivity- Type 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 10-20)

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:

5-10 foods only

Institute of Functional Medicine Diet: avoid gluten, corn, soy, dairy, shellfish, beef, pork, peanuts, eggs,

oranges, refined sugar

Lifestyle Eating And Performance Diet (LEAP) 6 Phase-diet based on results of MRT testing and clinical history

SWAG Diet:

Commonly Eliminated FoodsFatty 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 ReactionAnaphylactic ShockSingle Mechanism (IgE)

Delayed ReactionCan Be Dosage RelatedMultiple MechanismsDifficult to Identify Culprits

Cells Involved in Reaction:

Mast CellsPossibly Basophils

T-CellsNK CellsNeutrophilsMonocytesEosinophilsBasophilsPlatelets

Mechanisms Which Trigger Mediator Release:

IgE IgG, IgM, IgAC3, C4Immune CellsLectinsToxins

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

 Date/Time

 Meds/

supplements taken

 Food Eaten, Amounts and

Description: brand preparation, etc.

Symptoms?What and how severe (1-10)

Monitor adherence to the diet

Keep the patient engaged and accountable

Track even minute changes over time

Detective Work!

IBS-D PATIENT PLASMA CYTOKINES DURING D-EPISODE v BETWEEN EPISODES

0

50

100

150

200

250

300

350

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

See Specific Cytokine Key

pg

/ml Series1

Series2

Series3

1 IL-2

2 IL-4

3 IL-6

4 IL-8

5 IL-10

6 GM-CSF

7 IFN-g

8 TNF-a

9 IL-1b

10 IL-5

11 IL-7

12 IL-12

13 IL-13

14 IL-17

15 G-CSF

16 MCP-1(MCAF)

Patient on LEAP diet

Patient off LEAP diet

Cytokine Profile of Individual D-IBS Patient

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.

References1. 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

erinpeisachnutrition@gmail.com

www.nutritionbyerin.com

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