6/10/2016
1
The image part with relationship ID rId14 was not found in the file.
Beyond Belly Aches
Food Allergies and
Intolerances
Mark H. DeLegge, MD
Professor of Medicine
Digestive Disease Center
Medical University of SC
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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
SW2
Slide 3
SW2 Should be worded as it is in the abstract, have changed wording on the slide
Sheila Weiss, 7/31/2012
6/10/2016
2
The image part with relationship ID rId14 was not found in the file.
Food Hypersensitivity
The image part with relationship ID rId14 was not found in the file.
Symptoms
SW21
The image part with relationship ID rId14 was not found in the file.
Gut Immune System
Slide 5
SW21 Do you have a reference for this?Sheila Weiss, 8/6/2012
6/10/2016
3
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
Manifestations of a Food Allergy
Often a combination of several syndromes
• Anaphylaxis/Respiratory
• Skin Syndromes
• Gastrointestinal Syndromes
SW24
The image part with relationship ID rId14 was not found in the file.
Respiratory
• Anaphylaxis
• Rhinitis
• Wheezing
• Give Epinephrine injection with auto injector.
SW4
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
6/10/2016
4
The image part with relationship ID rId14 was not found in the file.
Skin Syndromes
Urticaria / Angioedema:• Acute urticaria predicts risk for future anaphylaxis• Food allergy more common in patients with atopic
dermatitis
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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
Slide 10
SW6 Is there enough to discuss here, as symptoms are described on slide 9?Sheila Weiss, 7/31/2012
6/10/2016
5
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
Cow’s Milk Allergy
The image part with relationship ID rId14 was not found in the file.
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
6/10/2016
6
The image part with relationship ID rId14 was not found in the file.
IgE-Related Food Allergy
Very different than a non-IgE-related food allergy
SW14
SW25
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
Food Intolerance
SW26
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
6/10/2016
7
The image part with relationship ID rId14 was not found in the file.
Commonly Believed Food Intolerances
Lactose
Gluten (celiac disease or intolerance)
The image part with relationship ID rId14 was not found in the file.
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
Place SR Logo Here
Varying Degrees of Lactose Sensitivity
The image part with relationship ID rId14 was not found in the file.
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%
Place SR Logo Here
6/10/2016
8
The image part with relationship ID rId14 was not found in the file.
Pathophysiology of Lactose IntolerancePathophysiology of Lactose Intolerance
Colonic Fermentation
SW23
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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
Slide 22
SW23 Do you have a reference for this?Sheila Weiss, 8/6/2012
6/10/2016
9
The image part with relationship ID rId14 was not found in the file.
Hydrogen Breath Test
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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.
Place SR Logo Here
6/10/2016
10
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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%)
The image part with relationship ID rId14 was not found in the file.
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
Place SR Logo Here
6/10/2016
11
The image part with relationship ID rId14 was not found in the file.
The Unintended Consequences
People who avoid milk and milk products due to perceived lactose intolerance miss many
benefits
Place SR Logo Here
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
The image part with relationship ID rId14 was not found in the file.
One Size Does Not Fit All
The image part with relationship ID rId14 was not found in the file.
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
6/10/2016
12
The image part with relationship ID rId14 was not found in the file.
What is Celiac Disease?
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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
Slide 34
SW27 Consider using a different graphic of wheat, or foods with gluten.Sheila Weiss, 8/6/2012
6/10/2016
13
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
Diagnosis of Celiac Disease
• Blood Tests – Auto-antibodies (TGG)• Intestinal Biopsy – Gold standard
• Symptoms – May overstate the prevalence
The image part with relationship ID rId14 was not found in the file.
Villous Height Under a Microscope
6/10/2016
14
The image part with relationship ID rId14 was not found in the file.
“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.
The image part with relationship ID rId14 was not found in the file.
Dermatitis Herpatiformis
Skin Manifestation of Celiac Disease
The image part with relationship ID rId14 was not found in the file.
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)
6/10/2016
15
The image part with relationship ID rId14 was not found in the file.
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.)
The image part with relationship ID rId14 was not found in the file.
Trademark Logos for Gluten-Free Products
Treatment is Elimination of Gluten From Diet (or Reduction?)
SW19
The image part with relationship ID rId14 was not found in the file.
Gluten-Free Grains and Starches
AmaranthArrowrootBuckwheatCornFlaxMilletMontinaOats*
PotatoQuinoaRiceSorghumTapiocaTeffFlours made from nuts, beans and seeds
*For possible cross-contamination with gluten-containing grains
Slide 44
SW19 These are fuzzy images. Are there better ones available?Sheila Weiss, 8/1/2012
6/10/2016
16
The image part with relationship ID rId14 was not found in the file.
Controversy in Dietary Interventions
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
Report Out
• Very controversial
• Not for treatment of
“food allergies.”
• No adequately
powered, prospective,
randomized, blinded
clinical trials
• Many case reports of
success
6/10/2016
17
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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
The image part with relationship ID rId14 was not found in the file.
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
SW32
Slide 51
SW32 Could you simplify the bullets, so that they include only the main ideas?Sheila Weiss, 8/6/2012
6/10/2016
18
The image part with relationship ID rId14 was not found in the file.