Allergy Awareness

Introduction

What are food allergens and food sensitivities? This is an area of heightened awareness today. While there is much we know about allergens, there is still much we need to learn. What we do know is that there is no cure for food allergies; strict avoidance is the only way to prevent a reaction.

There are more than 15 million Americans who are allergic to one or more food products included in the "Big 8"—the most common food allergens in the United States—which we will cover in more detail later. In the food industry, we must be especially aware of allergies and the foods and components of food that cause allergic reactions. Each year there are 30,000 allergy-related emergency room visits and 150 deaths attributed to food allergies. For your clients, food allergies are truly life and death!

One in 25 individuals, or 4% of the population, have food allergies. As a point of comparison, 8% of the U.S. population has diabetes, a much more visible concern.

Objectives

After completing this CE course, you'll be able to:

• Describe various methods used in the diagnosis and management of food allergies
• Explain current research into the treatment and prevention of food allergies
• State examples of best practices in prevention of food-allergic reactions

Definition of a Food Allergy

For our purposes, we'll define food as a substance that may be processed, semi-processed, or raw and intended for consumption. This includes additives, drinks, gums, and supplements.

A food allergy is an adverse health effect arising from a specific immune response that occurs when a person comes into contact with a food to which he or she has previously been sensitized. However, this term is broadening to encompass any immunologic reaction to a component of a food that results in symptoms. Food allergens are chemical components of food (usually proteins) that are recognized to elicit an immune reaction.

Our immune systems exist to prevent diseases caused by viruses, bacteria, or toxins. A food allergy occurs when the body reacts similarly to an allergen. We call this initial contact sensitization. Once someone has been sensitized, the body's immunologic defense will kick in, resulting in an allergic reaction with symptoms.

Phases of Food Allergy Development

Development of a food allergy occurs in phases:

• Sensitization Phase: The sensitization phase is the body's initial exposure to the allergen. There are almost never any symptoms accompanying this phase. The body will form allergen-specific IgE (Immunoglobulin E) antibodies upon the initial exposure to the food allergen.
• Early Phase (or Re-Exposure): Mast cells in the body are full of inflammatory agents such as histamine. After sensitization, the allergen-specific IgE created binds to the surface of mast cells, creating a cross-link. This turns the mast cells into little bombs waiting to go off upon re-exposure. When re-exposure occurs, these mast cells release the histamine and other mediators in a process called degranulation. This is the point at which physical symptoms begin manifesting themselves
• Late Phase: Leukocytes, or white blood cells, may continue to cause additional inflammation 2-24 hours after the initial reaction. This is the reason a hospital must watch a person experiencing severe allergic reaction for a minimum of 4 hours, to ensure there is not a re-reaction or late onset reaction from the same offending protein.

Oral Allergy Syndrome

Oral Allergy Syndrome, also known as pollen-food syndrome, is a condition that can affect people who also have hay fever. It manifests as an itchy or scratchy feeling in the mouth. It is caused by cross-reacting allergens in pollen, raw fruits, vegetables, and some tree nuts. The cross-reactivity occurs when the body's immune system recognizes proteins similar to those to which the body has been sensitized in these foods and an allergic response occurs. Onset of this syndrome is most common among older children, teens, and young adults, and not typically in young children.

The only time you would ever hear an allergy expert tell you cooking a food neutralizes the allergens in it may be in the case of Oral Allergy Syndrome. It has been found that heating the food alters the proteins enough in the offending fruits and vegetables to prevent the immune system from recognizing them and causing an allergic response.

Most common examples of pollens that may be present in fruits and vegetables that can trigger Oral Allergy Syndrome are:

• Ragweed Pollen: found in bananas, cantaloupe, chamomile tea, cucumbers, Echinacea, honeydew, sunflower seeds, tomatoes, watermelon, and zucchini
• Birch Pollen: found in apples, almonds, carrots, celery, cherries, coriander, fennel, hazelnut, kiwi, parsley, peaches, pears, and plums
• Grass Pollen: found in celery, melons, oranges, peaches, and tomatoes
• Natural Rubber Latex (NRL): found in bananas, avocados, kiwi, chestnuts, and papaya

FPIES (Food Protein-Induced Enterocolitis Syndrome)

FPIES is a food allergy affecting the gastrointestinal tract. Symptoms of FPIES include profound vomiting, diarrhea, and dehydration. These symptoms can lead to severe lethargy, changes in body temperature, and altered blood pressure.

This is a serious condition that often affects very young children and can require hospitalization. The American College of Allergy, Asthma & Immunology says that most children outgrow FPIES by age 3 or 4.

How does FPIES come to light? According to the FPIES Foundation, infants or children with FPIES might come to medical attention when severe, repetitive vomiting or diarrhea follows ingestion of a food. A typical timeframe is 2-3 hours after ingestion. Findings may include low blood pressure, dehydration, lethargy, and pale of blue coloration. According to the FPIES Foundation, "Many infants who are eventually diagnosed with FPIES are initially suspected to have a severe infection or sepsis."

An infant with FPIES who continues to consume the problem food over time may experience poor growth, and may develop symptoms that look like a total-body infection. Common triggers are infant formula—including soy or dairy, rice, oats, chicken, turkey, or fish.

A component of treatment for FPIES may be hypoallergenic formula, e.g., a casein hydrolysate-based formula, and substation of yellow fruits and vegetables for cereal.

Intolerances and Sensitivities

Any type of food reaction, regardless of severity or type, is considered a food sensitivity. Based on its severity, the classification is then further divided into:

• Intolerance (least severe)
• Allergic response
• Allergic reaction (IgE mediated)
• Anaphylaxis (most severe)

An intolerance is still an adverse reaction, but it is not caused by an immune system response, such as with an allergen. In this case, the body is not capable of digesting, absorbing or metabolizing the food or a component of a food.

U.S. News & World Report recently covered the new trend in testing for food sensitivities (not allergens). They report that sensitivities caused by enzyme deficiencies, histamines, tyramine, or sulfites can be identified by testing. However, many other "sensitivity" tests have not been validated.

Diagnosing Intolerances

An intolerance can be diagnosed via blood tests:

• Antigen Leukocyte Cellular Antibody Test (ALCAT) - Invented and patented by Dr. Mark Pasula and introduced in the 1980s, this test measures a cell once and cannot differentiate between cells. As one of the earliest tests developed, it is quite unreliable.
• Mediator Release Test (MRT) - This test, also invented by Dr. Pasula, measures each cell 90 times and each antigen approximately 1 million times for a more precise result. The newest version will measure inflammatory response to individual types of blood cells. Recently renamed the NowLeap test, it should not be confused with the "LEAP" study in London.
• PinnerTest: Microarray IgG (Immunoglobulin G) test for Permanent and Temporary Food Intolerances and Sensitivities - This test has the highest Specificity Rating (90%) of all three. It is the European Union standard, and was just launched in the United States at the end of 2014. This test does not need to be administered by a physician; it may be done at home with a kit provided by a PinnerTest representative. A simple finger prick and blood droplet are all that is required. The packet and sample are sent to the lab in Italy, and results are emailed.

The Big 8 Food Allergens and More

While more than 160 foods can cause allergic reactions, U.S. law defines 8 as most common. This list is called the Big 8:

• Eggs
• Fish (e.g., bass, cod, and flounder)
• Milk
• Peanuts (from the legume family, NOT tree nuts)
• Shellfish (crustaceans such as crab, lobster, and shrimp)
• Soybeans
• Tree nuts (almonds, walnuts, and pecans)
• Wheat

These eight foods account for approximately 90% of all food allergies in the U.S. However, according to the CDC, more than 220 other foods have been documented as causing the remaining 10% of allergic reactions.

Beyond the Big 8

Some of these other foods include molluscan shellfish (such as clams, mussels, and oysters), strawberries, mustard, sesame seeds, celery, black pepper, MSG, and stone fruit (any fruits with a pit, like cherries, avocados, and peaches).

There is ongoing discussion in scientific and policy communities about adding to the Big 8 list.

Our counterparts in Canada and the UK include many of the products mentioned above to their mandatory labeling and acknowledgment lists. They include the United States' "Big 8" plus:

• Canada: Mustard, sulfites, and sesame
• UK: Mustard, sulfites, sesame, celery, molluscan shellfish, and lupin (a flower used in flour production). It is also part of the legume family and is highly cross-reactive for individuals with a peanut allergy.

Diagnosing a Food Allergy

Diagnosing a food sensitivity, intolerance, or allergy is a lengthy process for most individuals. There are multiple processes and tests one must go through in order to be officially diagnosed with any of these allergies.

Initially, a thorough history and physical evaluation must be performed by a licensed allergist. This is followed by these four components of the diagnostic process: daily food journal, skin tests, blood tests, and double-blind placebo controlled food challenge.

Daily Food Journal - This is the most important tool in the initial food allergy diagnosis. It acquaints both physician and patient with current diet and any underlying symptoms. It will help the patient with education, understanding, and implementing safe practices while grocery shopping and dining out, like reading food labels. The daily food journal allows a physician to truly understand what the patient is ingesting and the effect it has on the body. Without this, it's impossible to begin the process.

Diagnosing a Food Allergy (continued)

Skin Tests - There are two types of skin tests performed in allergy diagnosis:

• The Prick, or Scratch Test is the most common type. In this test, a tiny drop of anywhere from 10 to 50 different allergens are pricked or scratched into the skin. This is also called a percutaneous test. It takes 5 to 10 minutes to place the allergens into the skin, usually on the forearm in adults and on the back in children. After about 15 minutes, if a small red lump appears where any of the allergens were placed, the patient is allergic to that food substance. The skin may itch where any bumps appear. The larger the bump, the more sensitive the patient is to that allergen.
• The Intradermal Test shows whether someone is allergic to things such as insect stings and penicillin. In this test, a small amount of the possible allergen is injected under the skin through a thin needle.

These tests may hurt slightly, and there may be itchiness and discomfort where the allergen was placed.

Diagnosing a Food Allergy (continued)

Blood Tests - There are two blood tests used to detect food allergies. The tests measure Immunoglobulin E (IgE) levels in the patient's blood.

• RAST is an abbreviation for RadioAllergoSorbent Test, a trademark of Pharmacia Diagnostics, which originated the test. RAST is a laboratory test used to detect IgE antibodies to specific allergens.
• ELISA stands for Enzyme-Linked ImmunoSorbent Assay and is used to measure the amount of allergen-specific antibodies in your blood. The ELISA is more sensitive than the RAST and is the more commonly used test in diagnosis today.

Double Blind Placebo Controlled Food Challenge (DBPCFC)

A Double Blind Placebo Controlled Food Challenge (DBPCFC) is one technique for diagnosing a food allergy. Double Blind Placebo refers to an investigative technique in which both the subject and the physicians are unaware of what substance is being provided. A suspect food is mixed in with another food so its identity is disguised. Alternately, the food may be provided in capsule form. This "blind" approach prevents both the patient and the physician from responding based on familiarity of a food or an expectation of adverse effects.

This test is performed in a medical office for safety, and the patient is monitored carefully for reactions.

According to The Cleveland Clinic, "Someone with a history of severe reactions cannot participate in a food challenge test. In addition, multiple food allergies are difficult to evaluate with this test."

The DBPCFC test is an effective, but expensive, method for confirm or ruling out specific food allergies.

Cross Contact or Cross Contamination

Cross contact occurs when one food comes into contact with another food and the proteins mix. Usually it is such a small, trace amount that it is not visible, making it very dangerous from a food-allergic person's perspective.

The term "Cross contamination" is often used in foodservice establishments and more commonly refers to foodborne illness. However, similar principles apply. In either case, surfaces or foods that have been in contact with allergens should never come into contact with foods being served to an allergic individual.

What's All the Hype About?

Every three minutes, a food-allergic reaction sends someone to the emergency room.

Food allergies are the most common cause of anaphylaxis in U.S. emergency rooms, accounting for 30% of all cases.

Experts estimate that there are 50,000 anaphylactic reactions, 2,000 hospitalizations, and 150 deaths annually from food allergies.

How Allergies Affect Lifestyle

Once a diagnosis is made, the patient and the patient's family are inundated with a daunting amount of information. The patient's diet changes completely. Suddenly, he or she must read every food label prior to eating anything. Cooking at home becomes more challenging, as the cook must proceed as if the entire house has an allergy. Everyone around the patient must be educated about the necessary precautions and risk factors.

Allergen awareness, tolerance, and sensitivity must be built into how we go about our daily lives. For those individuals who live with food allergies, everyday events become much more complex. Take for instance:

• Travel - Airlines, who for years served a complimentary snack of peanuts to their passengers, have come under a great deal of pressure from specific groups and organizations to remove peanuts from their flights altogether. But what about the non-allergic passengers? If they are not made aware of the needs of allergic passengers, how will they know what they know what snacks they can or cannot carry with them onto the flight?
• Parties and celebrations - Think of the last time you threw a party. Did you find out about your guests' possible food allergies beforehand? If so, did you speak to them directly to make certain how their food should be prepared?
• School lunchrooms - With all the recent attention paid to serving healthy lunches in schools, more schools have installed salad bars. The salad bar, however, is off limits for a child with food allergies, as is any other self-serve style lunch line.
• Restaurants and dining areas - Individuals with food allergies are sure to make note of a restaurant's understanding of food allergies and its reputation for accommodating food-allergic guests. College campuses and healthcare dining areas must observe the same precautions and sensitivities as restaurants.

Legal Concerns for Foodservice

Training, education, and proper standard operating procedures can make all the difference. It is not just an organization's reputation on the line; it is a matter of life or death to those with food allergies.

Recent cases involving everything from packaged cereal bars and grocery store cookies to burger bars and Mexican restaurants have resulted in the deaths of children as young as 11 years old to full-grown adults.

Foodservice operators may be held liable in such cases. In a landmark case in the UK, Mohammed Khalique Zaman, the owner of several award-winning establishments, was charged with manslaughter by gross negligence following the death of 38 year-old Paul Wilson, who had eaten takeout from one of Zaman's restaurants. Wilson, who was peanut-allergic, ate a curry dish in which peanuts had been used instead of almonds without any notification to customers of the substitution.

In another important case, Amanda Thompson, a British midwife and mother of two died while vacationing in Greece. She had made her allergies to eggs, milk, and apples known to both the travel agent and the hotel at which the incident occurred. During a meal specially prepared for her needs, she began to experience tingling in her tongue after eating sorbet. She returned to her hotel room, collapsed, and never regained consciousness.

A Greek pathologist ruled her death heart failure due to natural causes, but Thompson's family believed it to be the result of anaphylactic shock brought on by an ingredient in the sorbet, which was confirmed over a year later by a British pathologist.

The delay in formally declaring Thompson's death a case of food allergy-induced anaphylaxis demonstrates the difficulty in reporting and documenting food allergies.

Food Allergies after a Blood Transfusion

Allergen sensitivity can occur at any time in someone's life, in response to seemingly unrelated events.

Canadian research has found that food allergies can be temporarily passed to others through blood transfusion. Such cases are extremely rare, but could result in patients developing potentially fatal anaphylactic reactions to previously tolerated foods. The research began after an eight year-old boy with no history of allergies undergoing chemotherapy and blood product support had an allergic reaction after eating salmon. Four days later he experienced a reaction to peanuts. Investigators traced the source to just one donor who had these known food allergies, with an acute reaction to peanuts, tree nuts, shellfish, and all other fish, including salmon. Researchers said food allergies could be passed on through the transfer of IgE in blood platelets, although instances are extremely uncommon.

As reported by The Telegraph, Dr. Julia Upton of The Hospital for Sick Children in Toronto said, "It is very unusual to identify someone who experienced passive transfer of allergy from blood products." Importantly, this condition has an excellent prognosis and typically resolves within a few months. Upton also said allergies were too common to rule out transfusions from those who suffer from them.

The Tick Bite and Red Meat Cross-link

A gentleman living in the Southeast experienced an allergic reaction two to three hours after consuming red meat. This was unusual, since most allergic reactions occur within an hour after consumption. After visiting an immunologist, it was discovered that through a tick bite, he had developed an allergy to alpha-gal, a carbohydrate found in red meat.

In these cases, the body is sensitized by a bite from the Lone Star tick, creating alpha-gal-specific IgE antibodies. The body then reacts to alpha-gal in red meat by releasing histamine, causing sneezing, itchy eyes, runny nose, and other symptoms. Fatty meats in particular have a higher concentration of alpha-gal and the fat causes the reaction to be delayed.

Ongoing Research and Therapy

Viaskin Patches - DBV Technologies is developing Viaskin®, a proprietary, patented technology for administering an allergen to intact skin while avoiding transfer to the blood, and thus lowering the risk of a systemic, allergic reaction in the event of accidental exposure.

Hypoallergenic Peanuts - Scientists at North Carolina A&T University have found a way to reduce the allergen Ara h1 to virtually undetectable levels and allergen Ara h2 by up to 98% without affecting the taste.

LEAP Study

This clinical trial investigated how best to prevent peanut allergy. 640 children, age 4 to 11 months, identified as high risk for peanut allergy via an existing egg allergy and/or severe eczema were chosen for the study, and split into two groups and followed through the age of five.

One group followed a course of consumption equivalent to six grams of peanut protein per week. The second group strictly avoided peanut-containing foods throughout the study.

The study found that the consumption group had a 3% occurrence of peanut allergy, while the avoidance group had a 17% occurrence. The trial's conclusion was that consumption prevents subsequent development of the allergy in high-risk infants.

J.J. Levenstein, MD, explains on the peanutallergy.org website, "Parents of high risk children should feel more confident, and perhaps even elated, that they can reduce their child's potential risk of allergy to peanuts through early introduction."

Fish oil and probiotics

In addition, new research indicates that consumption of fish oil supplements during pregnancy can reduce a child's risk of developing allergies. Likewise, consumption of probiotics during pregnancy can reduce the risk of a child developing eczema.

In Conclusion

Food allergies affect everyone. Whether it concerns the safety of school children, or ensuring that restaurant guests can dine with peace of mind, it is important to understand what food allergies are, which foods can trigger them, the severity of food-allergic reactions, and how to effectively prevent them from occurring.

As foodservice operators, understanding food allergies and how to address them with sensitivity is essential—for your guests' safety, comfort, and the success of your organization.

Test Your Understanding

Please select the best answer for each question below.

Sources & Further Reading

• Allergen Management: Challenges and Trends. Food Safety Magazine. December 2014.
• American College of Allergy, Asthma & Immunology. Food Protein-Induced Enterocolitis Syndrome (FPIES).
• American College of Allergy, Asthma & Immunology. Oral Allergy Syndrome.
• American College of Allergy, Asthma & Immunology. Skin Test.
• Cell Science Systems. Food Sensitivity Testing with the Alcat Test.
• Cleveland Clinic. Food Challenge Test.
• DBV Technologies. DBV Technologies Confirms Planned Initiation of Viaskin® Peanut Global Phase III Clinical Trial in Children Following End-of-Phase II Meeting with FDA and PIP approval by EMA.
• DBV Technologies. DBV Technologies Announces Completion of Part A of the MILES Study Evaluating the Safety of Viaskin(R) Milk in Pediatric Cow's Milk Allergy.
• Daily Mail Online. British mother-of-two, 50, collapsed and died from allergic reaction after eating a sorbet on holiday in Greece.
• Daily News. Probiotics and fish oil in pregnancy man reduce child allergies. February 28, 2018.
• Decker et al. J Allergy Clin. Immunol. 2008:122:1161-65.
• FDA. Food Allergies: What you need to know. Accessed March 2018.
• FoodNavigator-USA.com. Medicated patch, hypoallergenic peanuts reduce nut’s allergy threat.
• Mahr, Todd A. MD and Lynn Christie, MS, RD, LD. Unraveling the Science of Food Allergy. 2013 Food and Nutrition Conference & Expo. October 20, 2013.
• Marish Health Blogs. Differences Between the ALCAT Test, RAST Test, and MRT.
• Immune Tolerance Network. A clinical trial investigating how to best prevent Peanut Allergy.
• National Institutes of Health. NIAID Scientists link cases of unexplained anaphylaxis to red meat allergy. November 28, 2017.
• National Peanut Board and J.J. Levenstein. Managing peanut allergies. peanutallergy.org, accessed March 27, 2018.
• Oxford Biomedical Technologies. MRT III: The Future of Food Sensitivity Testing.
• Pinner Test. What is a Pinnertest?
• The FPIES Foundation. What is FPIES?
• The Independent. Indian restaurant owner charged with manslaughter after customer dies from peanut allergy.
• The Telegraph. Allergies could be passed on through blood transfusions. 
• The Washington Post. If you’re allergic to meat, antibiotics and other additives may not be the reason.
• U.S. News & World Report. Should you get tested for food sensitivities? March 12, 2018.

Do you have questions or comments about this CE course?

We'd love to hear from you! Contact:

Josh Nissen
Sr. Brand Manager
Michael Foods, Inc.
Email: josh.nissen@michaelfoods.com