9781405170369_1_pre.qxd 22/12/2008 14:52 Page i Food Hypersensitivity Diagnosing and managing food allergies and intolerance Food Hypersensitivity: Diagnosing and managing food allergies and intolerance Edited by Isabel Skypala and Carina Venter © 2009 Blackwell Publishing Ltd. ISBN: 978-1-405-17036-9 9781405170369_1_pre.qxd 22/12/2008 14:52 Page iii Food Hypersensitivity Diagnosing and managing food allergies and intolerance Edited by Isabel Skypala BSc Nutrition and Dietetics, PG Dip Allergy, RD Specialist Allergy Dietitian, Director of Rehabilitation and Therapies, Royal Brompton & Harefield NHS Trust, andHonorary Senior Lecturer, Imperial College London Carina Venter BSc Dietetics, PG Dip Allergy, PhD, RD Senior Allergy Dietitian, David Hide Asthma and Allergy Research Centre, Isle of Wight, andSenior Research Fellow, University of Portsmouth A John Wiley & Sons, Ltd., Publication 9781405170369_1_pre.qxd 22/12/2008 14:52 Page iv This edition first published 2009 © 2009 Blackwell Publishing Ltd Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell. Registered office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom Editorial offices 9600 Garsington Road, Oxford, OX4 2DQ, United Kingdom 2121 State Avenue, Ames, Iowa 50014-8300, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell. The right of the authors to be identified as the authors of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Food hypersensitivity : diagnosing and managing food allergies and intolerance / edited by Isabel Skypala, Carina Venter. p. cm. Includes bibliographical references and index. ISBN 978–1–4051–7036–9 (pbk. : alk. paper) 1. Food allergy—Diagnosis. 2. Food allergy—Diet therapy. I. Skypala, Isabel. II. Venter, Carina. RC596.F668 2009 616.97′50654—dc22 2008047431 A catalogue record for this book is available from the British Library. Set in 10/12.5pt Sabon by Graphicraft Limited, Hong Kong Printed in Singapore by Utopia Press Pte Ltd 1 2009 9781405170369_1_pre.qxd 22/12/2008 14:52 Page v Contents List of contributors ix Foreword xi PART 1: DIAGNOSIS 1 Classification and Prevalence of Food Hypersensitivity 3 Carina Venter 1.1 Introduction 3 1.2 Nomenclature and classification 3 1.3 Immunological basis of food allergy 6 1.4 Symptoms associated with food hypersensitivity 9 1.5 Prevalence 9 1.6 Conclusion 17 2 The Role of Food Hypersensitivity in Different Disorders 22 2.1 The role of food hypersensitivity in skin disorders 22 Rosan Meyer and George Du Toit 2.2 The role of food hypersensitivity in respiratory disorders 31 Isabel Skypala 2.3 The role of food hypersensitivity in gastrointestinal disorders 37 Miranda Lomer 2.4 The role of food hypersensitivity in behavioural disorders 58 Donna C. McCann, Zoe Connor 2.5 The role of food hypersensitivity in neurological disorders 68 Sue Luscombe, Susan Thurgood 2.6 The role of food hypersensitivity in musculoskeletal disorders 81 Anna Carling 3 The Diagnosis of Food Hypersensitivity 85 Carina Venter, Berber Vlieg-Boerstra and Anna Carling 3.1 Introduction 85 3.2 Clinical history 85 3.3 Diagnostic tests 86 3.4 Complementary and alternative medicine 90 3.5 Diagnostic exclusion diets 92 3.6 Oral food challenges 94 3.7 Conclusion 103 9781405170369_1_pre.qxd 22/12/2008 14:52 Page vi vi Contents 4 Triggers of Food Hypersensitivity 107 Isabel Skypala 4.1 Introduction 107 4.2 Allergens and the immune system 107 4.3 Food allergen classes and nomenclature 108 4.4 How does a food allergen induce allergy? 108 4.5 Classification of food allergens 109 4.6 Advances in food allergen technology 110 4.7 Peanut allergens 111 4.8 Food labelling 112 PART 2: DIETARY MANAGEMENT 5 Milk and Eggs 117 Tanya Wright and Rosan Meyer 5.1 Introduction 117 5.2 Cow’s milk 117 5.3 Egg allergy 128 6 Seafood 136 Isabel Skypala 6.1 Introduction 136 6.2 Prevalence and natural history 136 6.3 Foods involved 137 6.4 Diagnosis 139 6.5 Avoidance 142 7 Fruits and Vegetables 147 Isabel Skypala 7.1 Introduction 147 7.2 Prevalence and natural history 147 7.3 Foods involved 149 7.4 Presenting symptoms and diagnosis 157 7.5 Management 160 8 Peanuts, Legumes, Seeds and Tree Nuts 166 Ruth Towell 8.1 Peanuts 166 8.2 Other legumes 171 8.3 Seeds 174 8.4 Tree nuts 176 9 Food Hypersensitivity Involving Cereals 183 9.1 Coeliac disease 183 Norma McGough, Emma Merrikin and Emily Kirk 9.2 Allergy to wheat and other cereals 203 Isabel Skypala 9781405170369_1_pre.qxd 22/12/2008 14:52 Page vii Contents vii 10 Other Causes of Food Hypersensitivity 210 Isabel Skypala 10.1 Reactions to food additives 210 10.2 Pharmacologic food reactions 221 10.3 Food-dependent exercise-induced anaphylaxis 229 PART 3: OTHER ASPECTS OF MANAGEMENT, ALLERGY PREVENTION AND NUTRITIONAL CONSIDERATIONS 11 Nutritional Consequences of Avoidance, and Practical Approaches to Nutritional Management 243 Ruth Kershaw 11.1 Introduction 243 11.2 Assessment of dietary adequacy 243 11.3 Factors affecting nutritional status 245 11.4 Ensuring optimal nutritional status while following a food-avoidance diet 246 11.5 The nutritional consequences of avoiding a number of common food allergens 247 11.6 Vitamin and mineral supplements 257 11.7 Other common nutritional issues encountered when implementing food-avoidance diets 260 11.8 Conclusion 262 12 Lifestyle Issues 265 Tanya Wright 12.1 Introduction 265 12.2 The burden of anaphylaxis and food allergy 265 12.3 The importance of reintroduction of foods 265 12.4 Cross-contamination 266 12.5 Items on prescription 266 12.6 Recipe information 267 12.7 Product information 267 12.8 Awareness products 268 12.9 Nurseries, childminders and carers 268 12.10 Managing food allergy at school 269 12.11 Managing food allergy at home 270 12.12 Managing food allergy at work 271 12.13 Eating out 271 12.14 Going on holiday 272 12.15 Support and resources 273 13 Allergy Prevention and the Effect of Nutrition on the Immune System 278 Carina Venter 13.1 Introduction 278 13.2 Introduction to the immune system 279 13.3 Supporting the immune system through nutrition 282 13.4 Conclusions 294 9781405170369_1_pre.qxd 22/12/2008 14:52 Page viii viii Contents 14 Management of Allergic Disease 303 14.1 Allergic rhinitis 303 Samantha Walker 14.2 Asthma 309 Jane Leyshon 14.3 Atopic eczema 315 Helen Cox 14.4 Anaphylaxis 322 Samantha Walker Appendix 1: Patient information literature for a food challenge 329 Appendix 2: Food challenge protocol for adults 331 Appendix 3: Food challenge procedures 335 Appendix 4: Prolonged open food challenge procedures 337 Appendix 5: Food challenge form 339 Appendix 6: Food challenge symptom score chart 342 Appendix 7: Dietary management summaries 345 Index 355 9781405170369_1_pre.qxd 22/12/2008 14:55 Page ix List of contributors Anna Carling, BSc, PG Dip Allergy, RD Senior Dietitian, Royal United Hospital, Bath NHS Trust Zoe Connor, BSc, RD, MSc Dietitian and Freelance Nutrition Consultant, www.nutritionnutrition.com Helen Cox, MBChB, FRCP, FRCPCH, MD Consultant in Paediatric Allergy and Immunology, Imperial College Healthcare NHS Trust George Du Toit, MBBCh, DCH, FCP, M Med, Dip Allergy, FRCPCH, FAAAAI Consultant in Paediatric Allergy, Evelina Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust and King’s College London Ruth Kershaw, BSc, RD Specialist Paediatric Allergy Dietitian, Lecturer in Human Nutrition and Dietetics (Placement Support), London Metropolitan University Trust Emily Kirk, MNutr, RD Coeliac Disease Specialist Dietitian, Coeliac UK Jane Leyshon, RGN, BA(Hons) Community Health Studies, PGCE Head of Academic Studies, Education for Health Respiratory Nurse Specialist in General Practice Miranda Lomer, PhD, RD Consultant Dietitian in Gastroenterology, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London Sue Luscombe, Dip Allergy, RD Specialist Dietitian, Bedford Hospital NHS Trust Donna C. McCann, PhD, MA, PGCE Visiting Research Fellow, School of Psychology, University of Southampton Norma McGough, BSc, RD Head of Diet & Health, Coeliac UK Emma Merrikin, BSc, RD Coeliac Disease Specialist Dietitian, Coeliac UK 9781405170369_1_pre.qxd 22/12/2008 14:55 Page x x List of Contributors Rosan Meyer, B Dietetics, M Nutrition, PhD, RD Paediatric Research Dietitian, Department of Paediatrics, Imperial College London Isabel Skypala, BSc Nutrition and Dietetics, PG Dip Allergy, RD Specialist Allergy Dietitian, Director of Rehabilitation and Therapies, Royal Brompton & Harefield NHS Trust and Honorary Senior Lecturer, Imperial College London Susan Thurgood, BSc, RD, Cert Nut Med Senior Specialist Dietitian, Royal London Homoeopathic Hospital Ruth Towell, BSc (Hons) Nutrition, MSc Teaching and Learning, RD Clinical Research Dietitian, Paediatric Allergy, King’s College London and Guy’s and St Thomas’ NHS Foundation Trust Carina Venter, BSc Dietetics, PG Dip Allergy, PhD, RD Senior Allergy Dietitian, David Hide Asthma and Allergy Research Centre, Isle of Wight and Senior Research Fellow, University of Portsmouth Berber Vlieg-Boerstra, PhD, RD Clinical Research Dietician, Paediatric Allergy, University Medical Centre, Groningen, The Netherlands and Specialist Allergy Dietician , Vlieg & Melse Dieticians, Arnhem, The Netherlands Samantha Walker, RGN, PhD Director of Education & Research, Education for Health, Warwick and Honorary Senior Lecturer (non-clinical), Division of Community Health Sciences, University of Edinburgh Tanya Wright, BSc, RD, MSc Allergy Specialist Dietitian and Allergy Services Coordinator, Buckinghamshire Hospitals NHS Trust