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Beyond Belly Aches

Food Allergies and

Intolerances

Mark H. DeLegge, MD

Professor of Medicine

Digestive Disease Center

Medical University of SC

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Disclosures

• Board Member/Advisory Panel oAmerican Board of Physician Nutrition Specialists

• ConsultantoCORAM HealthcareoBaxter HealthcareoCook Medical

• Othero 2013 FDA speaker expenses and honorarium

sponsored by National Dairy Council

Mark H. DeLegge, MD

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Objectives

After this presentation, the attendee will be able to:

• Identify and discuss research surrounding food intolerances and allergies including incidence, recent studies on intolerances, misdiagnosis and related statistics

• Differentiate food intolerances and food allergies based upon a firm understanding of the differentiating characteristics

• Identify appropriate interventions for food intolerances in order to help clients consume essential nutrients without discomfort

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Slide 3

SW2 Should be worded as it is in the abstract, have changed wording on the slide

Sheila Weiss, 7/31/2012

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Food Hypersensitivity

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Symptoms

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Gut Immune System

Slide 5

SW21 Do you have a reference for this?Sheila Weiss, 8/6/2012

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Food Allergies (IgE and non-IgE)

• More common in children than adults• 5% - 8% of pediatric population in some form• Most common allergens in children

o Milko Eggso Peanutso Tree nutso Soyo Wheat

Jason W.C. The Harriet Lane Handbook.8th ed.p:388.Mosby.2009

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Manifestations of a Food Allergy

Often a combination of several syndromes

• Anaphylaxis/Respiratory

• Skin Syndromes

• Gastrointestinal Syndromes

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Respiratory

• Anaphylaxis

• Rhinitis

• Wheezing

• Give Epinephrine injection with auto injector.

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Slide 8

SW24 Could you either (1) change this slide to a section header for slides 10-12, or (2) consolidate slides 10-12?Sheila Weiss, 8/6/2012

Slide 9

SW4 Is there enough to discuss here, as the symptoms are described on slide 9?Sheila Weiss, 7/31/2012

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Skin Syndromes

Urticaria / Angioedema:• Acute urticaria predicts risk for future anaphylaxis• Food allergy more common in patients with atopic

dermatitis

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Gastrointestinal Syndromes

• Oral Allergy Syndrome

o Edema of oral mucosa afteringestion of certain freshfruits and vegetables inpatients with pollen allergies

o Rarely progresses beyond the mouth

• Reflux, dysphagia, abdominal pain, diarrhea, early satietyo Characterized by an

eosinophilic infiltration of digestive tract on biopsy

Eosinophils

Colon Tissue

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Diagnosis

• Food allergy is suspected when typical symptoms occur with the introduction of specific foods

• Elimination diet and subsequent double-blind, placebo-controlled food challenge (DBPCFC) are the gold standard for diagnosis of food allergy

• In DBPCFC, suspected foods are administered in capsules in progressively increasing amounts, alternating with placebo, and reactions are evaluated in a blinded fashion

• Open food challenges , although commonly performed, are less reliable

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SW6 Is there enough to discuss here, as symptoms are described on slide 9?Sheila Weiss, 7/31/2012

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Treatment and Prognosis

The only therapy proved effective for food allergy is an elimination diet

• Most gastrointestinal manifestations resolve within several days , although some may take weeks (food-induced enteropathy).

• Respiratory and skin symptoms resolve over several days

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Cow’s Milk Allergy

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Cow’s Milk Allergy (Non-IgE Mediated)

• Presents in infancy• Most often resolves by age 2 or 3• Vomiting and diarrhea (may contain

blood)• Occasionally respiratory and skin

symptoms• When severe (rarely) may lead to

o lethargyo dehydrationo hypotensiono acidosis

• May occur with soy

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IgE-Related Food Allergy

Very different than a non-IgE-related food allergy

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IgE-Based Food Allergy

• Symptoms from IgE-mediated allergy to peanut, nuts, fish, or shellfish may not resolve without medical intervention

• Often may be lifelong allergy• The judicious use of a skin prick test or

radioallergosorbent test (RAST) can be very useful in determining whether an IgEallergic reaction is the cause of a food allergy

• Only treatment is food avoidance• Reaction can be life-threatening• Epinephrine-pen should be carried

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Food Intolerance

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Slide 16

SW14 Is IgE-Related FA the same as IgE-Based and IgE-Mediated? Notes on this section would be helpful to clarify what you will be discussing.Sheila Weiss, 8/6/2012

SW25 Are you looking for a picture for this slide? We are happy to provide.Sheila Weiss, 8/6/2012

Slide 18

SW26 Are you looking for a picture for this slide? We are happy to provide.Sheila Weiss, 8/6/2012

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Commonly Believed Food Intolerances

Lactose

Gluten (celiac disease or intolerance)

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Lactose Maldigestion

Incomplete digestion of lactose, the natural sugar in milk, due to low activity of the lactase enzyme; may be asymptomatic

Lactose Intolerance

Gastrointestinal disturbances following the consumption of an amount of lactose greater than the body’s ability to digest and absorb

Source: Lactose Intolerance, National Digestive Diseases Information Clearinghouse. December 15, 2011. http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/

J Natl Med Assoc. 2009;101:1S-24S

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Varying Degrees of Lactose Sensitivity

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Lactose Intolerance Prevalence Study

Source: Nicklas, TA, et al. Nut Today, Sept/Oct 2009.

19.50%

12% of Adults ReportBeing Lactose Intolerant

19.5%African

Americans

10.05%Hispanic

Americans

7.72%European Americans

Percent of Adults, by Ethnic Group, Who Self-Reported Lactose Intolerance

12%

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Pathophysiology of Lactose IntolerancePathophysiology of Lactose Intolerance

Colonic Fermentation

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Lactose

50 gm lactose produces 17L of hydrogen – large amount reabsorbed

Acetate gas

Butyrate gas

Propionic gas

Propionic gas

Colonic distention is perceived differently by patients

dependent on visceral sensitivity and/or hypersensitivity

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Clinical Symptoms Have Overlap With Other

Diseases

Lactose Intolerance• Abdominal pain

• Bloating

• Flatulence

• Diarrhea

• Vomiting

• Stools are usually bulky, frothy and watery

Irritable Bowel Syndrome

• Abdominal pain• Bloating• Flatulence• Diarrhea or constipation• Nausea and vomiting

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SW23 Do you have a reference for this?Sheila Weiss, 8/6/2012

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Hydrogen Breath Test

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Diagnosis of Lactose Intolerance

Symptoms: Self-reporting• Accuracy questioned

Tests: The following tests can be done:• Lactose Tolerance Test: drink a liquid of high

level of lactose, then measure the serum glucose levelo If the serum glucose level is not raised, means

lactose was not broken down

• Hydrogen Breath Test: drink a high level of undigested lactose gives large amount of hydrogen and gases because of the fermentation took place in the colon

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Why Lactose Intolerance Rates May Have Been Over-Estimated

New Estimates (2009) 1

• Based on self-reports• Reflect real life consumption

Previous Estimates (1988) 2

• Lactose maldigestion breath tests • Based on unrealistic amounts of

lactose • Findings widely misinterpreted

1. Nicklas, TA, et al. Nut. Today, Sept/Oct2009.2. Scrimshaw NS, et al. Am J Clin Nutr. 1988;48: 1083-1140.

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Symptomatic Diagnosis of Lactose Intolerance

• 10 cohort studies and 1

case-controlled study

• Evaluated diagnostic

performance of GI

symptoms as validated by

hydrogen breath test

Jellema et al: QJ Med 2010

Symptom Sensitivity

Range

Specificity

Range

Diarrhea .30-.80 .32-.84

Abdominal

Pain

.00-.85 .18-.73

Bloating .00-.84 .18-.96

Flatulence .10-.90 .08-.89

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Lactose Tolerance

• 182 subjects

• Symptoms of lactose

intolerance

• Mild to severe

• Milk consumption

determined

• Correlation of milk

consumption to symptoms

Rong q, et al. Biomed environ Med, 2011

Milk

Consumption

OR P-value

Duration .317 .001

Frequency .465 .046

Amount 6.337 .001

Odds ratio: how likely you are to have the

stated issue (1.0 = 100%)

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Lactose Intolerance:A Barrier to Dairy Consumption

Source: GFK Custom Research North America. DMI: Health Professionals Dairy Nutrition Tracking Study, January 2009

• More than 80 percent of pediatricians and dietitians agree that lactose intolerance is a major reason some people avoid milk and milk products

• Lactose intolerance is the number one barrier to health professional recommendations for dairy

• Most US residents do not consume recommended dairy intake

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The Unintended Consequences

People who avoid milk and milk products due to perceived lactose intolerance miss many

benefits

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Dairy and its essential nutrients are associated with:• Improved nutrient intake and diet quality• Better bone health • Weight management• Reduced risk of certain chronic diseases

Source: Miller GD, et al. Handbook of Dairy Foods and Nutrition, 2007U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DCU.S Government Printing Office, December 2010.Van Loan M. JACN, 2009; 28:120S-129S

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One Size Does Not Fit All

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For Those With True Lactose Intolerance

• Ingest smaller quantities of dairy products

• Consume dairy products with less lactose/ volume

• Use lactose-free products or ingestion of lactase enzymes

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What is Celiac Disease?

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Pathophysiology

• Gluten and gliadin are two proteins found in wheat, barley, rye that give flour its elasticity and is also a popular food additive

• Heavily used additive in baked goods, cereals,malt, caramel flavorings, breads, cookies and pastas

• Present as an additive in many processed foods

• Antigen/Antibody inflammatory reaction

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Prevalence of Celiac Disease

Healthy population- 1:1331st degree relatives - 1:18 to 1:22

2nd degree relatives - 1:24 to 1:39

Fasano, et al. Arch Intern Med 2003;163:286-92

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SW27 Consider using a different graphic of wheat, or foods with gluten.Sheila Weiss, 8/6/2012

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Presenting Features of Celiac Disease

Adults• Diarrhea, altered bowel habit including

constipation• Abdominal pain, dyspepsia, bloating• Aphthous ulcers – mouth• Anemia (Iron or folate and rarely vitamin B-

12)• Weight loss• Dermatitis herpetiformis• Malabsorption, edema• Osteoporosis, low impact fracture

McGough N, Cummings JH. Proc Nutr Soc 2005;64:434-450

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Diagnosis of Celiac Disease

• Blood Tests – Auto-antibodies (TGG)• Intestinal Biopsy – Gold standard

• Symptoms – May overstate the prevalence

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Villous Height Under a Microscope

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“A delayed allergic response to the proteins gluten and gliadin.”

This autoimmune allergic reaction primarily inflames the small intestine, however the effects of which can be felt throughout the entire body.

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Dermatitis Herpatiformis

Skin Manifestation of Celiac Disease

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What is the difference between Gluten Intolerance and Celiac Disease?

• Gluten intolerance is a constellation of symptoms secondary to the ingestion of gluten

• Gluten intolerance occurs with celiac disease testing being negative

• Patient reports symptoms improve following elimination of gluten from the diet

•There is controversy about this diagnosis because of the lack of a biomarker (diagnostic test)

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Digestive Signs and Symptoms Associated

with Gluten Intolerance

• Diarrhea• Constipation• Abdominal pain• Cramping• Dyspepsia• Gas• Bloating

• Heartburn• Gastroparesis• GERD• Esophagitis• Eosinophilic

gastroenteritis• Eosinophilic esophagitis• Canker sores• Apthous ulcers

*Systemic symptoms may also occur (migraine headach es, lethargy, asthma, etc.)

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Trademark Logos for Gluten-Free Products

Treatment is Elimination of Gluten From Diet (or Reduction?)

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Gluten-Free Grains and Starches

AmaranthArrowrootBuckwheatCornFlaxMilletMontinaOats*

PotatoQuinoaRiceSorghumTapiocaTeffFlours made from nuts, beans and seeds

*For possible cross-contamination with gluten-containing grains

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SW19 These are fuzzy images. Are there better ones available?Sheila Weiss, 8/1/2012

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Controversy in Dietary Interventions

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LEAP Diet(Lifestyle, Eating and Performance)

• MRT ( mediator release) testing

• Food Sensitivities

• Non-IgE mediators measured with food

extract exposure to patient blood cells

(antigenic challenge)

• Non-antigenic diet prescribed

• Symptoms followed

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Report Out

• Very controversial

• Not for treatment of

“food allergies.”

• No adequately

powered, prospective,

randomized, blinded

clinical trials

• Many case reports of

success

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ALCAT

• Patient’s serum tested

• Changes in the size of WBC after exposure to purified food extracts

• Size change > 13% considered diagnostic

Conditions treated

Migraine Headaches

Chronic Fatigue

Irritable Bowel Syndrome (IBS)

Attention Deficit Hyperactivity Disorder (ADHD)

Eczema and other skin disorders

Asthma and other respiratory problems

Weight Gain and Obesity

Arthritis

Fibromyalgia

Digestive Health

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ALCAT

• Test Results: Four Distinct Areas

Red

• Foods listed indicate a severe reaction and should be avoided at all costs for a minimum of 6 months.

Orange

• Foods listed indicate a moderate reaction and should be strictly avoided for a minimum of 3 to 6 months.

Yellow

• Foods listed indicate a mild reaction and should be avoided if possible, especially if there are few red and orange foods. If eaten, these should only be eaten on one day in four to prevent increased reactivity.

Green

• Foods listed indicate no reaction and can be eaten freely on a rotation basis, no more than every other day

• Very controversial

• Not for the diagnosis of food allergies

• No adequately powered, prospective, randomized, blinded clinical trials

• Many case reports of success

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Conclusion

• Food allergies and food intolerances are 2 very distinct diseaseso Non-IgE and IgE-associated food allergies with

very different prognosis

• Whereas food allergy requires the elimination of a particular nutrient, the same is often not true for food intolerances

• The diagnosis of food intolerances in the adult population may be overestimated as it is often based on patient self-reporting

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SW32 Could you simplify the bullets, so that they include only the main ideas?Sheila Weiss, 8/6/2012

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