FOOD ALLERGY

By

NURPUDJI ASTUTI

SCHOOL OF MEDICINEHASANUDDIN UNIVERSITY

MAKASSAR 2003

WHAT IS FOOD ALLERGY

Is a response of the immune system to a component of food, almost invariably a protein

OrA molecule linked to a protein, that the immune system recognizes as a foreign to the body

OrFOOD HYPERSENSITIVITY

IMUNOLOGICAL MECHANISMS OF ALLERGY

HYPERSENSITIVITY REACTIONS INVOLVE A SERIES OF SPECIFIC EVENTS AND RESULT IN CLINICAL SYMPTOMS.

EACH TYPE INVOLVES DIFFERENT COMPONENTS OF IMMUNE SYSTEM.

FOOD ALLERGY CAN BE MEDIATED BY Type I, Type III OR TYPE IV HYPERSENSITIVITY OR POSSIBLY BY COMBINATION OF THIS TYPES.

FOOD ALLERGY

IS COMMON IN INFANCY PREVALENCE 1 – 3% ONLY REPRESENTS A SMALL

PROPORTION OF FOOD REACTION IN THE ADULT.

SOMETIMES FOOD ALLERGY IS LIFELONG

TYPE I HYPERSENSITIVITY

INVOLVES IgE ANTIBODIES MAST CELLS OTHER GRANULOCYTES

SYMPTOMS ATOPY PERSON MUST BE SENSITIZED BY A FIRST EXPOSURE

TO THE ALLERGEN

SENSITIZATION B-CELL LYMPHOCYTES PRODUCE ALLERGEN SPECIFIC

IgE ANTIBODIES IgE MOLECULES COUPLE WITH RECEPTORS ON THE

SURFACE OF MAST CELLS ( IN TISSUES) AND BASOPHYL ( IN BLOOD)

NO SYMPTOMS ARE OBSERVED ON FIRST EXPOSURE TO THE ALLERGEN

TYPE III HYPERSENSITIVITY

INVOLVES IgM AND IgG CHEMICALS FORMED IN THE COMPLEMENT CASCADE STEP REACTION ARE:

T-cell lymphocytes recognize the antigen as foreign after it is processed by macrophages

IgM and later IgG are produced in response to the antigen

Ag-Ab complexes are formed The complement cascade is triggered Anaphylatoxins formed in the complement

cascade cause the release of inflammatory mediators

TYPE IV HYPERSENSITIVITY

T cell lymphocytes and cytokines Called as contact allergy T-cells lymphocytes respond to the

allergen - release of cytokine. An immediate reaction when thry come

into contact with the lips, tongue, mouth and GIT.

Example: Nickel allergy

Allergy as an Inflammatory Process

Symptoms of allergy result from the release of inflamatory mediators

Histamin – increases the permeability of capillaries – swelling

Rhinitis – is due to fluid buildup in tissues in nasal passages

Excessive fluid in the skin causes urticaria (hives) and angioedema

Histamin also causes itching and vasodelation, resulting in flushing or reddening of the skin

Continue ----

Allergy as an Inflammatory Process Prostaglandins caused vasodelation and

vasocontriction

Leukotrienes - contraction of smooth muscle – bronhospasm of asthma

Bradykinin in conjunction with prostaglandins causes pain.

Sometimes these inflammatory mediators are released or their levels are enchanced by mechanisms that are independent of the immune system – this situation considered to be INTOLERANCE rather than ALLERGY

INCIDENCE OF ALLERGY

5 – 15 % if neither parent has allergies 20 – 40% if one parent has allergies 40 – 60% if both parents have allergies 60 – 80% if both parents have the same

allergy 25 -35% if one sibling has allergies

FACTOR CONTRIBUTING TO THE EXPRESSION OF ALLERGY TO FOODS

INHERITED PHYSIOLOGICAL CONDITIONS

1. INCREASED PERMEABILITY OF THE INTESTINAL MUCOSA

2. IMMATURITY

3. INFLAMMATION IN THE DIGESTIVE TRACT

4. COMBINED ALLERGIC REACTIONS

5. ENCHANCES UPTAKE OF FOOD ALLERGENS

6. EXERCISE

7. CHANGES IN HORMONE LEVEL

8. STRESS

9. FREQUENCY OF EXPOSURE

ADVERSE REACTION TO FOOD ADDITIVES

FOOD ADDITIVES;

any substance, including any source of radiation, the used of which results, or may reasonably be expected to result, in it or its by products becoming a part of or affecting the characteristics of food

PRESERVATIVES AS COLORING AGENT ( to provide taste, odor, and texture )

Dyes such as tartrazine, erythrosine Preservatives such as: sulfites, benzoates, sorbates Flavoring agents and flavor enchancers;

monosodium glutamate (MSG) Ripening agents; ethylene Antioxidants; butylated hydroxyanisole (BHA) ,

butylated hydroxytoluene (BHT), sodium nitrite Emulsifiers, lecithin, polysorbate Texturizers; calcium chloride, Humectants; glycerine, propylene glycol Thickeners & stabilizers; gum tragacanth, agar-agar

SOURCE OF FOOD ADDITIVES

CHEMICAL ADDITIVES --- USED EXTENSIVELY IN MANUFACTURED FOODS

PROBLEMS FOR PERSONS WITH FOOD SENSITIVITIES CHEMICALS; DIVERSE IN COMPOSITION AND TYPES DERIVED FROM NATURAL SOURCES ( CHEMICAL

PROCESSES) & SYNTHESIZED FROM INORGANIC SOURCES.

??? ---- VERY LITTLE UNDERSTANDING OF HOW THE CHEMICAL CAUSES THE ADVERSE CLINICAL EFFECTS

CLINICAL REACTIONS TO FOOD ADDITIVES

Urticaria Angioedema Asthma Rhinitis Headache Irritable bowel syndrome

clinical reaction continues -----

HYPERACTIVITYFOOD COLORSPRESERVATIVESMANY FOODS

SENSITIVITY TO MONO SODIUM GLUTAMATESYMPTOMS RESEMBLE TO MYOCARDIAL INFARCTION, INCLUDING TIGHTNESS AND PAIN IN THE CHEST WHICH RADIATES TO THE ARMS, PALPITATIONS AND FAINTNESS.

IDENTIFYING SENSITIVITY TO FOOD ADDITIVES

SAIFER AND SAIFER

USED ANECDOTAL MARKERS, ONE OF THE SIGNS IS DEVELOPMENT OF SENSITIVITY TO ALCOHOL, STARTING WITH ADVERSE REACTIONS TO RED WINE & BEER, AND FOLLOWED BY WHITE WINE AND DESTILLED SPIRITS.

SENSITIVITY TO INGESTED CHEMICALS, SUCH AS GASOLINE, CIGARETTE SMOKE, PAINT SOLVENTS, HOUSE-HOLD CLEANERS

INDICATORS OF CHEMICAL FOOD ADDITIVE INTOLERANCE ARE MULTISYSTEM RAECTIONS, ESPECIALLY CENTRAL NERVUS SYSTEM SUCH AS: HEADACHE, FATIGUE, MUSCLE WEAKNESS, SKIN AND RESPIRATORY SYMPTOMS.

AT PRESENT, THE ONLY INDICATOR OF FOOD ADDITIVES INTOLERANCE IN MOST CASES IS ELEMINATION AND CHALLENGE WITH FOODS CONTAINING THE SUSPECTED ADDITIVE(S)

FOOD ADDITIVES MOST FREQUENTLY IMPLICATED IN ADVERSE REACTIONS

TARTRAZINE AND OTHERS FOOD DYES SULFITES NITRATES AND NITRITES BENZOATS SORBATES BUTYLATED HYDROXYANISOLE (BHA) BUTYLATED HYDROXYTOLUENE (BHT) SALICYLATES MONOSODIUM GLUTAMATE AND OTHER

GLUTAMATES

ANAPHYLACTIC REACTIONS TO FOODS

Occurrence of Anaphylactic reactions to foods

Person with asthmatic -- more likely than general population

Increased when the person is receiving desensitization injections or is allergic to wasp and bee venom

Most commonly food are ” peanuts, nuts, shellfish, fish, cow’s milk, and egg”

Most study --- 80% of atopic children are allergic to only one or two foods.

Continues ---

Anaphylactic reaction to cow’s milk, egg, wheat and chicken in children under three year of age

Infant and toddlers tend to outgrow early allergies to certain foods, such as milk, egg, wheat and soy

Food allergy occurs after 3 yo, the allergy is likely to be outgrown.

Allergies to certain other foods – to be outgrown or may persist for a person’s lifetime --- such as: peanuts, nut, shellfish and fish.

Foods implicated in anaphylactic reactions

NUTS

PeanutsPecanPistachioCashewBrazilpinom

Seeds

MilletSubflowerSesameCottonseed extractAnnatto ( color )Psyllum

Grains

WheatRice

Continues --

Vegetables Potato Celery Pea Pinto bean Soybean Chickpea Corn

Fruit orange Tangerine Mango Banana Kiwi fruit

Poultry chicken

EggHen

Fish Cod Halibut

Beverages Chamomile tea wine

Shellfish crab Shrimp Lobster Limpet

Milk products cow’s milk

ALLERGENIC CROSS-REACTIVITY BETWEEN BOTANICALLY RELATED PLANTS

CROSS REACTIVITY DEFINED AS A CONNECTION BETWEEN TWO OR MORE ALLERGENS, WHEATHER RELATED OR NOT, THAT CAUSES OF THEM TO INDUCE SIMILAR CLINICAL REACTIONS

NOT VALID PLANTS BELONG TO THE SAME FAMILY, THEY ARE NECESSSARILY RELATED ANTIGENECALLY

ALLERGIC REACTION TO A SINGLE SPECIES DOES NOT AUTOMATICALLY LEAD TO ALL MEMBERS OT THAT PLANT FAMILY

ALLERGENIC CROSS-REACTIVITY BETWEEN UNRELATED PLANT SPECIES

RECENT STUDY HAS DEMONSTRATED THE PRESENCE OF CROSS REACTING ANTIGRNS IN BOTANICALLY UNRELATED, ALLERGENIC PLANT SPECIES.

THE ALLERGENS MAY BE INHALED OR CONSUMED AS FOOD

COMMON ANTIGENS HAVE BEEN DEMONSTRATED WITHIN EACH OF THE FOLLOWING GROUPINGS:

1. BIRCH POLLEN, HAZELNUT, POTATO AND APPLE 2. APPLE, CARROT AND CELERY 3. BIRCH POLLEN, NUT, APPLE AND FRUIT WITH STONE 4. HAZELNUT, RYE GRAIN, SESAME SEEDS, KIWI, AND POPPY SEED 5. BIRCH POLLEN, MUGWORT POLLEN, APPLE, CELERY AND CARROT 6. BIRCH POLLEN, APPLE, CELERY, CARROT, POTATO, HAZELNUT, ORANGE, TOMATO AND PEANUT 7. REGWEED POLLEN AND WATERMELON 8. REGWEED POLLEN, MELON AND BANANA 9. LATEX, BANANA, AVOCADO, KIWI FRUIT, CHESTNUT, SOYBEAN, PEANUT, PAPAYA, FIG.

Continues ---- FOOD ALLERGY

Lesson two

THURSDAY, OCTOBER 16TH, 2003

Nurpudji AstutiNutrition Department School of Medicine

Hasanuddin University

ALLERGENIC POTENTIAL FOOD

TO WHAT EXTENT SHOULD A KNOWN ALLERGEN BE AVOIDED ???example: person allergic to soy, should all form of soy be eliminated from the diet, including hydrolyzed soy protein, lecithin made from soy, fermented soy ( soy sauce) and so on??

FOR SAFETY, THE ALLERGIC PERSON IS USUALLY ADVISED TO AVOID ALL FORMS OF THE FOOD.

IMPACT: great deal of work social economy stress annoyance nutritional deficiency fearful of ingesting the allergen --- fail to describe of

ingredients in manufactured foods.

DEGREE OF INDIVIDUAL REACTS

Depends on a number of factors, including the allergenic potency of the food.

Mildly allergic to food --- fewer precautions need be taken in detecting the food as hidden ingredient.

Avoid all --- allergic food precipitate a life threatening anaphylactic reaction.

FOODS MOST LIKELY TO CAUSE A SEVERE REACTION IN THE HYPERSENSITIVE PERSON

Peanuts

Green peas

Tree nut

Shellfish

Finfish

Egg white

Cow’s milk protein in infants

QUANTITY OF FOOD REQUIRED TO CAUSE AN ALLERGIC REACTION

Depend on the potency of the allergen The allergic person’s response

Sensitized adult is 20 grams Shrimp allergy will provoked with 1-2 grams of

shrimp Peanuts allergy can be precipitated by as little as

25 mg of peanut. Inhaling food component or handling can

precipitate a reaction in highly sensitive individual

Food additives derived from potentially allergenic foods

Name Source Foods likely to contain the additive

Function of foods

Lecithin

Annatto

EggEgg yolkSoy beanCorn

Extract from the seed of tropical tree

Boxed breakfast cerealCandyChocolatesBreads, rolls, burnsMargarine

Dairy products (cheese, butter)Breakfast cerealBaked goodsmargarines

Antioxidant and emollient composed of choline, phosphoric acid, fatty acids and glycerin

Coloring agent ( yellow to pink)

MILK ALLERGY BIOLOGICAL MECHANISMS

Results when the immune system produces antibodies against milk allergen

The allergenicity test using skin test and oral challenges Casein protein produced the highest # of positive skin tests in

children with milk allergy Children or adults react more than one milk protein

HEAT LABILE Serum protein and beta casein

THE MOST HEAT LABILE Beta - lactoglobulin Alpha - lactalbumin

ANTIBODIES produced against milk proteins may: IgE, IgM, IgG, sometimes IgA

MANAGEMENT OF MILK ALLERGY

Elimination dietary milk Foods containing milk Product from milk Liquid and evaporated milk Fermented milks (yogurt, buttermilk) Cream All cheeses Ice cream Ice milk

Food substitutes Milk provide:

protein, calcium and vitamin D

Protein substitute Readily available from fish, mat or

combinations of legumes, nut, grains Adequate dietary protein does not depend on

ingesting milk

Calcium substitute Canned fish such as tuna , sardines, salmon

eaten with the bones Green leafy vegetable: broccoli, beet, turnip Calcium from vegetable is not as readily

available as from animal sources

SUBSTITUTES IN MEALS AND RECIPES

Soy milk Mocha mix Rice dream ( brown rice = safflower oil ) Coconut milk Nut milk Whey- free margarine Non-diary creamers (vegetable oil products) Soy Bean curd or Cake (Tofu)

LACTOSA INTOLERANCE

Not involve a response by the immune system

No antibodies are produced

Enzyme lactase is insufficient to break down the quantity of lactose

consumed at any one time

Lactase produced by the brush border cells of the small intestine ---

damaged --- inflammation (infection or allergy) --- or congenital

characteristic, the sugar remain undigested – microbial enzymes

metabolize lactose –variety organic acid (lactic and propionic acids),

gases (hydrogen)– imbalance result from the exceed sugar and acid ---

water is drawn to correct the problem---- DIARRHEA

Symptoms are pain, bloating and gas due to bacterial fermentation of lactose

INCIDENCE OF LACTASE DEFICIENCY

Asian, Black African races, people from mediterranean region, lose of the ability to produce lactase

Starting five year of age Prevalence about 80% 20% of North European origin lose ability to produce lactase Lactase deficiency uncommon in infants---lactose is principal

sugar in human milk and infants require lactase to digest their mother’s milk.

Secondary lactase deficiency can develop in infant following a bacterial and viral infection of digestive tract--- diarrhea

Infant unable to tolerate lactose until the infection subsides and the intestinal mucosa recovers.

TREATMENT

COMPLETE DIETARY EXCLUSION OF COW’S MILK

70 -80% ALLERGIC TO COW’S ARE ALSO ALLERGIC TO GOAT’S MILK PROTEINS

MILK SUBSTITUTE IS USUALLY NECESSARY

Peanut allergy Peanuts are legumes

Peanuts and soy the most allergenic of the family leguminosae – 30 species – including fresh or dried peas and beans, all type lentils, soy beans, carob and licorice.

Symptomatic reactivity to more than one member of the legume family is rare

Reaction to peanut, soy, and other legume are managed separate allergies.

Peanuts are the most frequently cited causes of life threatening anaphylactic reactions

Once a person had had an anaphylactic reaction to peanuts, extreme caution must be exercised to avoid all sources of peanut

An allergy to nuts should be distinguished from an allergy to peanuts or other legumes, otherwise the diet can become stressful and cumbersome if all traces of peanuts are avoided, as well as all traces of other nuts.

Warning !!!!!!!!! Sometimes no differentiation is made in marketing

peanuts and other nuts, and the two are sold together in “ nut mixtures”.

In the manufacture of candies, confectioneries and ice creams, cross contamination occurs between nuts and peanuts.

Result – persons with severe peanut allergy should be advised to avoid any product containing any type of “NUT” because the danger of encountering peanuts inadvertently.

Symptoms of Peanut Allergy“the allergy is considered to be lifelong”

Urticaria Angioedema Wheezing Asthma Vomiting Rhinorrhea Itching --- contact dermatitis Nausea Allergic conjunctivitis anaphylaxis

Studies have indicated that peanuts allergic adult can tolerate pure peanut oil without any clinical reactions.

The allergic reactivity occurs to the protein not to the oil

However, because traces of the protein may contaminate the oil, individuals who are anaphylactic to peanut, or to any another plant, should be cautioned to avoid oil derived from allergenic plant.

EGG ALLERGY Mayor proteins for egg allergy present in egg white

OvalbuminConalbumin ( ovotransferrin )Ovomucoid

Yellow egg present as livetins derived from the blood of the hen

Cross reactivity may occur between white and yellow egg

Ovomucoid is heat stable, persons allergic to this component react to both cooked and raw egg

Ige Antibodies are produces to egg proteins, which differ from the protein in chicken flesh

FOODS CONTAINING EGGS AVOIDANCE OF EGGS AS AN INDIVIDUAL FOOD IN A

MEAL

SCRAMBLED, BOILED, FRIED OR

OMELETE EGGS INCLUDED AS AN INGREDIENT IN PREPARED

FOOD, MAY NOT BE EASILY RECOGNIZED

BOYH PRACTITIONER AND ALLERGY SUFFERER

NEED TO BE AWAREOF THE FOODS

TRADITIONALLY MADE WITH EGGS.

PROTEIN COMPOSITION OF EGGS

56 -61% OF THE WEIGHT OF CHICKEN EGGS IS THE WHITE

27 -32% IS YOLK

THE REST IS SHELL

EGG WHITE PROTEINS

OVALBUMIN

CONALBUMIN

OVOMUCOID

OVOMUCIN

LYSOZYME

EGG YOLK PROTEINS

LIPOVITELLIN

PHOSVITIN

LOW DENSITY LIPOPROTEINS

LIVERTONS

TRACE AMOUNTS OF OTHER PROTEINS

CATALASE OVOFLAVOPROTEIN FICIN INHIBITOR OVOGLYCOPROTEIN G2 AND G3 GLOBULINS OVOMACROGLOBULIN RIBONUCLEASE OVOINHIBITOR AVIDIN