Food Allergy – Indian Food Allergy – Indian ScenarioScenario
Dr. Ashok GuptaDr. Ashok GuptaAsso. Prof. of Pediatrics, SMS Medical College, JaipurAsso. Prof. of Pediatrics, SMS Medical College, Jaipur
Deputy Executive Director, International Society of Tropical PediatricsDeputy Executive Director, International Society of Tropical PediatricsExecutive, International Pediatric Academic Leaders AssociationExecutive, International Pediatric Academic Leaders Association
Medical Advisor, Food Allergy and Anaphylaxis Network, USAMedical Advisor, Food Allergy and Anaphylaxis Network, USAMember, EAACI Committee on Patient Group for Food AllergyMember, EAACI Committee on Patient Group for Food Allergy
Epidemiology of Diseases in IndiaEpidemiology of Diseases in India
S. No. Disease Total Cases Deaths Year
1 Acute Respiratory Infection 1,18,54,345 3736 2007
2 Acute Diarrhea Disease 94,78,813 2328 2007
3 Measles 26986 1995
4 Malaria 1363279 1066 2007
5 Japanese Encephalitis 4017 989 2007
6 Dengue 5395 69 2007
Continued…Continued…
• No registry of Food Allergy Patients
• No Medical college has a degree course in Allergy
• Demographic projections predict 22% of the total population suffer from some allergy (250 million)
CaseCase
• Avinash – 8 year, Male, h/o Peanut Allergy
visiting from USA– Consumes packaged food with inadequate
information, develops anaphylaxis
– July 6, 2010, Union Minister of Health, GOI accepted Food Allergy as a serious health problem
CaseCase
Anil – 1 yr. Male
• Milk Ingestion induces – flushing, swelling, breathing difficulty
• Milk anaphylaxis
CaseCase
Shrichand – 5 yrs. Male
• Repeated papular urticaria
• Partial response to antihistamines
• Allergy test – wheat allergy
• Improved on wheat withdrawal
CaseCase
Vicky – 5 yrs. male
• Chronic Diarrhea
• Failure to thrive
• Rickets
• Multiple nutritional deficiencies
• Celiac Disease
Adverse Food Reactions may be mistaken Adverse Food Reactions may be mistaken for allergy for allergy
Toxic / PharmacologicToxic / Pharmacologic Non-Toxic / IntoleranceNon-Toxic / Intolerance
• Bacterial food poisoning• Heavy metal poisoning• Scombroid fish poisoning• Caffeine• Alcohol• Histamine
Non-immunologic
• Lactase deficiency• Galactosemia• Pancreatic insufficiency• Gallbladder / liver disease• Hiatal hernia• Gustatory rhinitis• Anorexia nervosa• Idiosyncratic
Adapted from Sicherer S, Sampson H. J Allergy Clin Immunol 2006;117:S470-475.
• Eosinophilic esophagitis
• Eosinophilic gastritis
• Eosinophilic gastroenteritis
• Atopic dermatitis
Adverse Food Reactions Adverse Food Reactions
IgE-MediatedIgE-Mediated(most common)(most common)
Non-IgE MediatedNon-IgE MediatedCell-MediatedCell-Mediated
Immunologic
• Systemic (Anaphylaxis)
• Oral Allergy Syndrome
• Immediate gastrointestinal allergy
• Asthma/rhinitis
• Urticaria
• Morbilliform rashes and flushing
• Contact urticaria
• Celiac disease
• Protein-Induced Enterocolitis
• Protein-Induced Enteropathy
• Eosinophilic proctitis
• Dermatitis herpetiformis
• Contact dermatitis
10
Natural history of food allergyNatural history of food allergy
• Generally - reproducible reaction: same person, same food, same, similar or related symptoms
• May progress from dermatitis or hives to vomiting & wheeze to Asthma and Anaphylaxis
• ~ 85% of individuals with allergies to cows milk, egg, wheat, soy become tolerant by 3 yrs of age
• Allergy to peanut, nuts, seafood is typically permanent
Allergens Common in IndiaAllergens Common in India
• Any food can be allergenic• Patterns of common allergens differ across
regions and cultures• Dairy, eggs, peanuts, tree nuts such as walnuts,
almonds and cashews, fish, shellfish, soya, wheat, seasame top the list
• Incidence of allergies to milk, eggs and wheat less frequent then in the West
• Dals (Pulses) such as chickpeas more common allergy to rice has been reported
Allergy distributionAllergy distribution
• Evenly distributed
• More in urban and semi urban areas as compared to rural areas
• Changing food pattern moving away from Traditional Dal, Rice, Vegetables to Fast Food, Ice cream, Chocolate additionally increased Houses have Carpets & Pet
Food allergy
IgE-mediated food allergy
Non-allergicfood hypersensitivity
Non IgE-mediated food allergy
FoodhypersensitivityFood hypersensitivity
Food hypersensitivityFood allergy
IgE-mediated allergy
Non-IgE- mediatede.g. celiac disease
Non-allergic-foodhypersensitivity
Enzymatic- lactose intolerancePharmacological
- biogenic amines e.g. histamine, tyramine
Allergens from a single siteAllergens from a single site
No. of Tests- 66778 (2008 & 2009)Name of Allergen Percentage allocation
Mite 36.1
Cockroach 32.5
Asp.Fum. 28.8
H.dust 21.8
Bermuda grass 21
Shrimp 18
Johansson grass 15.9
Wheat 12.4
IgE mediated Food Allergens in patients with Asthma and allergic rhinitis.
No. of patients- 1860 patient.
Curd 48 %
Rice 43%
Citrus 35 %
Banana 27 %
Milk 12 %
blackgram 9.7 %
Egg 2.7 %
Chicken 1.5 %
Fish 1.2%
Studies on large scale surveysStudies on large scale surveys
• Moshe Ben-Shoshan etal, Montreal, Canada – Population based study on Peanut, Tree nut, Fish, Shellfish, and Sesame allergy prevelance in canada
• EuroPrevall
• Gerez etal – Singapore Medical Journal
Definition of Food AllergyDefinition of Food Allergy
• Perceived food allergy – Self reported
• Probable Food Allergy – Self reporting / Physician confirmed
• Confirmed Food Allergy – Convincing clinical history of IgE reaction / positive SPT
Methodology Methodology
• Telephone surveys
• Trained Interviewer
• Respondents 18 years older with no language mental hearing barriers
• Questionnaire
• Statistical Analysis
No. of New Celiac casesNo. of New Celiac cases
0
20
40
60
80
100
120
2002 2004 2006 2008 2010
Celiac Patient
Distribution of Celiac Diseases Distribution of Celiac Diseases CasesCases
Rural
Urban
24%
76%
ComplianceCompliance
• Rising incidence of symptomatic celiac patients• Need for appropriate education of parents,
children & medical personal• Need for strategies of prevention
- Delayed introduction of gluten- Breast Feeding
• High index of suspicious in children with Typical presentations & in asymptomatic IDA, Hypothyroid, 1st degree relicts.
• IDD & Hypothyroid not responding to treatment need to be screamed.
• Regulatory mechanism for labeling & assessing of gluten free products.
KAP Anaphylaxis
Medical College Faculty & Residents - 32%
General Practioner - 9.2%
Food Allergy diagnosis
Medical College Faculty & Residents - 44 %
General Practioners - 11.2%
ConclusionsConclusions
• Food allergy on the rise• Need for establishing a national registry• Urgent need to educate medical personnel • Social & Psychological cost to the patient and
the family• Food labeling• Scientific support on preventing food allergy &
making food safe• Quality control of marketed foods