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NUTRITION MANAGEMENT OF FOOD HYPERSENSITIVITIES

Description
This diet eliminates the offending food or foods that cause an adverse reaction.  Generally, the diet is the Regular Diet with the omission of the offending food.  Each individual’s sensitivity to the food determines the degree to which the particular food must be omitted. 

Indications
Food hypersensitivity is an immune response, generally from IgE, to food components.  The reaction results from an antigen of food source (usually protein) and may occur immediately (1 minute to 2 hours) or as a delayed reaction (2 to 48 hours) (1).  Allergic tendencies are inherited, but not necessarily to a specific antigen.  Foods most commonly reported to cause allergic reactions in children are cow’s milk, chicken eggs, peanuts, soy, and fish; in adults, the most common are tree nuts, peanuts, fish, shellfish and wheat (2-4).  The most common reactions to food allergies are gastrointestinal (eg, diarrhea, nausea, vomiting, cramping, and abdominal distention and pain), skin-related, and respiratory responses as well as systemic anaphylaxis with shock. 

    No simple test can be used to accurately diagnose the presence of a true food hypersensitivity.  Unidentified or misdiagnosed food hypersensitivities can cause fatal reactions, result in inappropriate treatments, and threaten nutritional status.  For the diagnosis of hypersensitivity, the following measures should be taken: a food reaction history, a physical examination, a 1- to 2-week diary recording foods eaten and symptoms, biochemical testing, immunologic testing, eg, skin tests such as, radioallergosorbent test (RAST) and the enzyme-linked immunosorbent assay (ELISA), a trial elimination diet for 2 weeks or until symptoms are clear, and a food challenge (2,5,6). 

    The history, used to identify the suspected food, should include detailed descriptions of symptoms, amount of food ingested, time of intake, and time of onset of symptoms.

    A trial elimination diet removes all suspected foods and reintroduces them one at a time; if the symptoms are reduced by 50% or more while the patient is on the diet, that food is suspected (5).  The food challenge is made after symptoms are cleared.  Although challenges can be open, single-blind, or double-blind, the double-blind, placebo-controlled food challenge (8) is the preferred method for diagnosis of food hypersensitivity.  Foods are provided in a pure form, and challenged one at a time, one per day.  After the trial elimination diet and food challenge, the patient’s diet should be altered eliminating the response-related food for 6 to 8 weeks (5).  These foods are challenged again, and if the patient does not react to them, the foods are returned to the diet on an occasional basis. 

Nutritional Adequacy
The trial elimination diet is intended to be short term because of its nutrient inadequacies.  Most eliminations that involve a single food can be planned to meet the Dietary Reference Intakes (DRIs) as outlined in the Statement on Nutritional Adequacy.   However, diets that eliminate cow’s milk may be low in calcium, vitamin D, and riboflavin.  If children must eliminate cow’s milk, the diet may also be low in protein and vitamin A.  Diets that restrict or eliminate eggs, meats, and fish may be deficient in protein.  Grain-free diets may be deficient in B vitamins, iron, energy, and carbohydrates.  Citrus-free diets may be deficient in vitamin C and folic acid.  Diets that eliminate multiple foods can be deficient in certain nutrients and should be evaluated, so that appropriate alternatives are recommended to supply nutrients that are lacking.  No food group should be completely eliminated on a permanent basis unless absolutely necessary.

How to Order the Diet
Order as “______-Free Diet” (specify food to eliminate).

Planning the Diet 
The basic diet should be the appropriate diet for the patient’s age.  Only foods confirmed by the food challenge should continue to be restricted.  It is important to personalize the patient’s diet based on food preferences.

    Labels and recipes should be carefully read to avoid ingestion of the food that causes a reaction.  Teaching the patient to read food labels, make appropriate substitutions, and purchase foods free of the suspected allergen, is the most helpful component to the self-management training.  Often this training will require more than one session.  Patients should be encouraged to contact food manufacturers with questions about ingredients.  The Food Allergy & Anaphylaxis Network (FAAN) has a Grocery Manufacturer’s Directory and small, pocket-laminated cards listing food terminology.

These resources are available for purchase directly from FAAN (10400 Eaton Place, Suite 107, Fairfax, VA 22030, 703/691-3179, Fax, 703/691-2713, email: fan@world web.net) (5).

    The following section lists ingredients and terms found on food labels, which indicate the presence of specific food allergens.

Corn-Free Diet
Ingredients to avoid:

  • Baking powder
  • Fructose
  • Corn, all types
  • Glucose
  • Corn flour
  • Hominy
  • Corn grits
  • Lactic acid
  • Corn malt
  • Maize
  • Corn meal
  • Maltodextrin
  • Corn starch
  • Modified food starch
  • Corn sugar; corn sweeteners
  • Popcorn
  • Corn syrups
  • Sorbitol
  • Dextrin; dextrose
  • Vegetable gum; vegetable starch
  • Equal® sugar substitute
  

Egg-Free Diet
Ingredients to avoid:

  • Albumin
  • Meringue (meringue powder)
  • Apovitellin
  • Ovalbumin
  • Cholesterol-free egg substitute
  • Ovoglobulin
  • Egg
  • Ovomucin
  • Egg powder
  • Ovomucoid
  • Egg whites, all forms
  • Ovovitellin
  • Globulin
  • Simplesse 
  • Livetin
  • Surumi
  • Mayonnaise

 

Milk-Free Diet
Ingredients to avoid:  

  • Artificial butter flavor; butter-flavored oil
  • Butter, butter solids
  • Malted milk
  • Milk:  whole, low-fat, reduced fat, and nonfat
  • Buttermilk
  • Milk chocolate
  • Casein; caseinates (ammonium, calcium, magnesium, potassium, sodium)
  • Milk derivative; milk powder; milk protein; milk solids; milk solid pastes
  • Cheese, all types; cheese flavor; cheese sauce; cottage cheese; cream cheese
  • Nonfat milk solids; nonfat dry milk
  • Nougat
  • Cream; sour cream; whipped cream
  • Curds
  • Pudding
  • Rennet casein
  • Custard
  • Ghee
  • Simplesse  
  • Sour milk solids
  • Goat’s milk
  • Sweetened condensed milk
  • Half-and-half
  • Hydrolysates (casein, milk, protein, whey, whey protein)
  • Whey: curd, lactose-free, demineralized, sweet dairy; whey protein concentrate; whey solidsYogurt; frozen yogurt; yogurt powder
  • Ice cream
  • Lactalbumin; lactalbumin phosphate; lactoglobulin
  • Lactate solids
  • Foods that may indicate the presence of milk protein: caramel candies, high protein flour, non-dairy products
  • Lactose
  • Lactulose