Foundation for Integrated Medicine Food Allergy Leo Galland M.D. Foundation for Integrated Medicine.

Foundation for Integrated Medicine

Food Allergy

Leo Galland M.D.



HOW PREVALENT IS FOOD ALLERGY/INTOLERANCE?

• 33% of 1000 teachers (56% response rate) reported avoidance specific foods because of “unpleasant” physiological reactions.

• A poll of 5000 US physicians on prevalence of food allergy (14% response rate): 0-80% (mean 10%)


Immunologic Mechanisms of Food Intolerance

• Type I (IgE mediated, TH2 promoted)

• Type II (IgG and complement mediated, cytotoxic, TH1 promoted)

• Type III (IgG immune complex mediated, TH1 promoted)

• Type IV (cell-mediated, TH1 promoted)


Non-immunologic Mechanisms of Food Intolerance

• Digestive (e.g., lactase deficiency)

• Pharmacologic (e.g., caffeine, ethanol)

• Biochemical (histamine, tyramine, salicylates, sulphites, MSG)

• Non-specific mast cell degranulation

• Lectin-mediated glycoprotein agglutination


Poor Sulphoxidation and Food Allergy (Scadding 1988)

• 74 adults with non-IgE food allergy diagnosed by elimination and challenge

• 78% slow carbocisteine sulfoxidizers vs 33% of controls (p<0.005)

• Carbon oxidation (debrisoquine): normal• Theory: altered metabolism of food

chemicals toxic/immunogenic metabolites by novel pathways


FOOD ALLERGY/INTOLERANCE: WELL-DOCUMENTED MANIFESTATIONS

• Atopic Eczema• Allergic Rhinitis, Asthma• Anaphylaxis, Angioedema,

Urticaria• Oral Allergy Syndrome

(Ortolani)• Aphthous Ulceration• Alveolitis, Hemosiderosis• Infantile Colic• Vomiting, Diarrhea,

Abdominal Pain• Irritable Bowel Syndrome• Hematochyzia, Colitis

• Pediatric Enteropathies• Celiac Disease• Protein-losing Enteropathy• Failure to thrive• Crohn’s Disease

(exacerbation)• Migraine headches• Migraine-associated Epilepsy• ADHD• Nephrotic Syndrome• Allergic Arthritis• Rheumatoid Arthritis

(exacerbation)


FOOD ALLERGY IN PEDIATRIC ATOPIC ECZEMA

• 25-60% are food reactive• Increased gut permeability

– at baseline– after food challenges– blocked by cromolyn

• Histamine release• Circulating immune complexes• Multi-system reactivity in 2/3

– 49% gastrointestinal– 23% rhinitic– 17% asthmatic

• Poor correlation between food responses and prick tests, RAST: milk, egg, citrus, additives, nuts, fish, wheat, tomatoes, lamb, chicken, soy


FOOD ALLERGY IN PERENNIAL RHINITIS

(Ortolani et al)

210 patients over 1 year

3-week oligoantigenic diet

52 improved (24.8%)

28 IgE mediated (13.3%), based upon correlation with RAST, skin testing

24 no correlation


FOOD ALLERGY IN RECURRENT APHTHOUS

STOMATITIS

• Cytotoxic lymphocytes/antibodies

• Histamine release to foods (23/60)

• 30% correlation of HR and ulcers

• Gluten, milk, food additives


FOOD ALLERGY IN HYPERKINETIC SYNDROME

(Egger et al, Lancet 1985)

76 children seen on referral

(60 boys, 16 girls)

age 2-15 (mean 7.3)

37 from dysfunctional families

4 weeks’ oligoantigenic diet

2 meats, 2 starch sources, 2 fruits,

1 vegetable, calcium, multivitamin


RESPONSE TO OLIGOANTIGENIC DIET IN HYPERKINETIC SYNDROME

Pre-diet DietTotal number 76 76

Hyperactivity: Normal 0 21 Mild 6 28 Moderate 31 19 Severe 39 8Conners’ score 24 12Antisocial acts 32 13Headache 48 9Seizures 14 1Abdominal pain 54 8Limb pain 33 6Eczema, rash 29 9Aphthous ulcers 15 5Atopic (prick test) 30 (39%)


Summary of Egger’s Results

• Open trial: 82% of children responded favorably to the oligoantigenic diet

• DBPCT: 28 participated, with rating of response by parents, a neurologist and a psychologist

• DBPCT: 51-74% of the food intolerances confirmed


FOODS PROVOKING HYPERACTIVITY IN DOUBLE-BLIND, PLACEBO-CONTROL TRIAL

% REACTIVE Additives 79

Soy 73

Milk 64

Chocolate 59

Grapes 50

Wheat 49

Oranges 45

Cheese 40

Eggs 39

Peanuts 32

Corn 29

Fish 23

Oats 23

Melon 21

Tomato 20


Cognitive-Emotional Symptoms and Food Allergy (King, 1981)

• DBPCT: 30 adults, 28 food extracts, sub-lingual, multiple measures, 2 judges

• Symptoms associated with allergen exposure: anxiety, depression, brain fog, irritability, detachment, euphoria; pruritus, cold hands, myalgia, nasal congestion, tinnitus, fatigue, headache

• Occurrence p=0.001, Severity p=0.002


FOOD ALLERGY IN PEDIATRIC MIGRAINE (Egger, 1983)

88 children, oligoantigenic diet

93% cleared by 2 weeks

90% relapsed on open challenge

40 of these, DBPC TRIAL

26 confirmed (4 reacted to placebo, 8 reacted to neither)

Atopy 55%, 46% hyper, 16% seizures

Milk, egg, chocolate, orange, wheat

benzoate, cheese, tomato, tartrazine, rye, fish,

pork, beef, corn, soy, tea


MIGRAINE-ASSOCIATED SYMPTOMS AND FOOD INTOLERANCE

88 PATIENTS

Pre-diet Diet

Abdominal pain,

diarrhea 61 8

Hyperactivity 41 5

Limb pain 41 7

Rhinitis 34 15

RAS 15 2

Vaginal discharge 11 1

Asthma 7 3

Eczema 6 3

27/40 provoked by DBPC food trial

10/40 provoked by placebo also

3/40 provoked by neither


EVIDENCE FOR ALTERED IMMUNE ACTIVATION IN RESPONSE

TO FOODS IN MIGRAINE(Marteletti 1991, Acta Neurologica)

• Increased circulating immune complexes• Increased activated T cells and total T cells• Increased plasma IL-2 levels• Effective prophylaxis with oral sodium

cromoglycate


Food Allergy in Idiopathic Nephrotic Syndrome

• Basophile histamine release test +

- 65% of 34 patients

- 5% of 19 controls

wheat, beef, milk, egg, pork

• 26 patients with refractory nephrosis

- 6 remitted on oligoantigenic diet


TM, a 26 old woman with massive proteinuria, anasarca

• Prior: aesthetician, applying artificial nails, developed asthma, multiple inhalant allergies, provoked by allergy immunotherapy

• Severe anasarca emergency hospitalization, furosemide, steroids

• Proteinuria 4 gm/day, serum albumen 1.3 gm/L, marked hyperlipidemia, normal biopsy

• Required prednisone 20 mg/day maintenance



• Initial evaluation: Cushingoid, 3+ proteinuria• Method: modified fast, supported by a rice-

based, oligoantigenic food supplement, tapering down prednisone and daily examination of urine protein by dipstick

• Result: clearing of proteinuria in 7 days, return of proteinuria within 24 hours of ingesting hen’s eggs

• Total remission for 7 years, avoids eggs


Food Intolerance and Rheumatoid Arthritis

• 5-46% of patients in various studies have exacerbation of symptoms provoked by specific foods, mostly wheat, milk, tomatoes, various additives, some confirmed with DBPC trials

• An 18-year open study of foods provoking pain in 100 patients found that certain spices and food additives were commonest agents


GLUTEN INTOLERANCE IS PREVALENT AND PROTEAN

• Gliadin antibodies were found in 30/53 patients with neurological disease of unknown cause (73% had abnormal small bowel biopsies)

Hadjivassiliou et al, Lancet 347: 369-371 (1996)

• IgG and IgA gliadin antibodies occur in 2% of Italian school children

Catassi et al, Lancet 343: 200-203 (1994)


Cow’s Milk Allergy and IDDM

• Children with IDDM have IgG against a peptide fraction of bovine serum albumen that cross-react with a pancreatic beta-cell surface protein

• Adults with recent-onset IDDM show excessive T-cell proliferation in response to beta-casein, compared to normal and auto-immune controls