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I Can’t Eat That! Food Allergies in Corrections.
Ada County JailBoise, Idaho
Introduction
Case 1--38 year old man states that he is deathly allergic to onions and must have an onion free diet.
Case 2--19 year old man states that he is allergic to peanuts and has avoided them since childhood.
Case 3—29 year old female states she is allergic to milk. She requests a substitute for milk in her diet trays.
Goals
Understand IgE mediated allergic reactions
Know the incidence and risk of Food Allergy adverse events.
Know how to confirm food allergy by history and testing.
Adverse Food Reaction
Toxic Food Reaction
Food Intolerance Food Allergy
Non-IgE mediated ▪ (Celiac Disease)
IgE mediated
Toxic Food Reaction
Salmonella
Hangover
Food Intolerance
Food Allergy Non-IgE Mediated Most occur in
children < 3years old
Local reactions Poison Ivy reaction Food allergy
causing oral reactions
Celiac disease Not acute Takes time to
diagnose
IgE Allergy Mechanism
IgE sensitized.Attaches to Mast
CellAwaits next
encounter with the allergen.
IgE Allergic Reaction
Allergen attaches to IgEMast cell destabilizesReleases
HistamineProstaglandinsLeukotrienes
IgE Allergic Reaction
Urticaria Angioedema Respiratory Anaphylaxis
Urticaria and angioedema are by for the most common allergic reactions
Allergic reactions--Urticaria
Angioedema
Respiratory bronchospasm
Anaphylaxis
Cardiovascular symptoms Hypotension Vascular collapse
In conjunction with skin and respiratory symptoms
Other Manifestations of Allergic Reaction
Gastrointestinal Hypersensitivity Usually kids Vomiting, diarrhea, cramps Minutes to 2 hours after eating. In conjunction with hives and
angioedema. Exercise induced food allergy
IgE Allergic Reaction
Occurs in seconds to minutes.
Takes only a small amount of allergen to cause reaction.
Food Allergy Epidemiology Mostly a disease of
childhood
Allergies tend to abate with age
Food Allergy Epidemiology
CHILDREN
Cow’s MilkEggsWheatPeanuts, Tree
nuts
ADULTS
PeanutsTree nutsShellfish
Fish
Fruits and vegetables
Food Allergy Deaths
Food Allergy Deaths: 100/year
Penicillin allergic deaths: 400/year
Latex allergy anaphylaxis: 220/year
NSAID related deaths: 25,000/year
Food Allergy Deaths
Most deaths are teenagers/ young adults
>85% are due to peanuts and tree nuts
Virtually all had asthma. Virtually all had had a
previous severe reaction to the same food.
Virtually all did not receive epinephrine in a timely fashion.
Diagnosis—Detailed History
Right Age?Right Food?Emergency treatment?Allergist? Testing?EpiPen? Medic Alert?Restaurants? Shopping labels?
Diagnosis—Food Trial
Diagnosis--Testing
Skin Prick Test Easy to do. Inexpensive. Results in 15
minutes. Requires training
and supplies. Great for large
jails.
CapRAST
ImmunoCap Radioallergosorbent test
Measures IgE to specific antigens.
Accurate and predictable.
$45.00. Is this cost effective?
CapRAST
Positive defined as greater than 2.0kU/L
Sensitive but not specific.
CapRAST
CapRAST
CapRAST
Summary—Cap RAST
Sensitive, not specific. If negative, believe it. If positive, the patient still may not
be allergic. Expensive--$45.00. May be less expensive than the costs
of a special diet.
Incidence in Corrections
Of those referred to an allergist, <50% are actually allergic.
What about those coming into a jail or prison?
Food Allergy Incidence Ada Co. Jail
Ada County Jail is a 1200 bed facility located in Boise, Idaho.
Over a two year period, virtually all inmates who stated they had a food allergy were tested.
Ada County results
Allergen Number of Tests
Number Positive
Percent Positive
Peanuts 39 5 13%
Finfish (Tuna, Cod)
34 0 0
Cow’s Milk 12 0 0
Vegetables 10 0 0
Oatmeal, Wheat, Rice, Gluten
10 0 0
Shellfish 5 2 40%
Tree nuts 5 0 0
Fruits 4 0 0
Poultry 4 0 0
Beef 3 0 0
Egg 2 0 0
Introduction
Case 1--38 year old man states that he is deathly allergic to onions and must have an onion free diet.
Case 2--19 year old man states that he is allergic to peanuts and has avoided them since childhood.
Case 3—29 year old female states she is allergic to milk. She requests a substitute for milk in her diet trays.
Treatment Considerations Risk of
anaphylaxis. Food avoidance. Emergency
response.
Risk Assessment
HIGHER RISK
Teens to Early 20s
Previous severe reaction
Peanuts, Treenuts, shellfish
LOWER RISK
Older
Not the Big 3 foods
No documentation of previous severe reaction
Treatment—Food Avoidance
Special Diet
Kitchen Worker?
Cell or dorm where others eat the allergic food?
Treatment—Emergency Response
Epipens?
Emergency Response?
Food Allergy Prevention
Don’t serve “The Big 3 Foods”
Substitute Foods. Testing--skin prick
test and CapRAST.
Food Allergy Prevention #3 Work up protocol
Peanuts, fish CapRAST, Skin prick
test Tomatoes, onions,
etc. History test CapRAST, Skin Prick
Food Allergy Protocol
CATEGORY: MEDICAL AND NUTRITION TOPIC: FOOD ALLERGIES PURPOSE: TO GUIDE APPROPRIATE IDENTIFICATION AND TREATMENT OF PATIENTS WITH FOOD ALLERGIES References. This protocol is based upon the following sources.
Adkinson: Middleton’s Allergy: Principles and Practice, 7th ed. Chapter 65—Adverse Reactions to Foods Food Allergy: Diagnosis and Management. Primary Care: Clinics in Office Practice. Vol. 35, issue 1 (March 2008) Rakel: Integrative Medicine, 2nd ed. Chapter 86—Adverse Food Reactions and the Elimination Diet
Introduction to food allergies in corrections In a correctional setting, the differentiation of true food allergies from food intolerance (especially simple food aversion) is essential. On the one
hand, jails do not want someone with a true food allergy to be served that food and suffer an allergic reaction. On the other hand, most inmates who claim to have a food allergy only have a food aversion and jails cannot feasibly grant a special diet to everyone like this.
Inmates who have no true allergy may use the claim of an allergy to avoid foods they do not like, in order to gain status among other inmates and to manipulate staff.
The goal of this endeavor is to accurately identify those individuals with a true food allergy and exclude those who do not have a true food allergy.
Definitions. Food Allergy refers to an immune-mediated allergic reaction to the glycoproteins in certain foods.
▪ Food allergies are most common in the very young.▪ Many patients with true food allergies loose the allergy over time.▪ Several studies indicate that most patients who report a true food allergy are found by diagnostic testing to not have that allergy in fact.▪ Most cases of true food allergies are to certain foods: nuts, shellfish, eggs.▪ An estimated 200 people die each year from acute allergic reactions.▪ Most of these deaths are due to peanut or tree nut allergies.
Food Intolerance refers to any non-allergic reaction to food. Food intolerance includes:▪ Food poisoning due to a toxin.▪ Side effects of substances found in some foods (example, headache caused by tyramine in wine or racing heart caused by caffeine).▪ Individuals lacking certain digestive enzymes, such as those with lactose intolerance and those needing pancreatic enzyme replacement.▪ Food aversion in which patients have a psychological revulsion for certain foods but experience no problems when they ingest that food unknowingly.
Adverse Food Reaction includes both food allergy and food intolerance. This term is used when it is not yet known if a patient has a true allergy or not.
Case One
38 year old man states that he is deathly allergic to onions and must have an onion free diet.
Right Age? Right Food?History--ER? Allergist? Testing?EpiPen? Medic Alert?Restaurants? Shopping labels?
Case Two
19 year old man states that he is allergic to peanuts and has avoided them since childhood.
Right Age? Right Food?History--ER? Allergist? Testing?EpiPen? Medic Alert?Restaurants? Shopping labels?
Case 3—Milk Allergy
An IgE milk allergy in an adult is rare.
The most common causes of milk “allergy” are:
Intolerance (eats ice cream and cheese)
Lactase deficiency (truly avoids dairy)
Treatment is Lactaid—on commissary.
Slides Outline Ada County Jail
Food Allergy Protocol
Questions
