Module III.

Food allergies and intolerance

 Types of Reaction
 Food as allergens, their symptoms, diagnosis
 Treatment

FOOD ALLERGY
An allergic response is a reproducible adverse reaction to a substance mediated by an
immunological response.
The substance provoking the reaction may have been ingested, injected, inhaled or merely
have come into contact with the skin or mucous membranes.

What is a Food Allergy?

 A food allergy occurs when the body’s immune system sees a certain food as harmful
and reacts by causing symptoms.
 This is an allergic reaction. Foods that cause allergic reactions are allergens.

Food intolerance does not imply any specific type of mechanism and is simply defined as a
reproducible adverse reaction to a specific food or food ingredient.
Food aversion comprises food avoidance, where the subject avoids a food for psychological
reasons such as distaste or a desire to lose weight, and psychological tolerance.

DIFFERENCE BETWEEN FOOD ALLERGY AND FOOD INTOLERANCE:

Feature Food Allergy Food Intolerance

An immune system reaction to a A digestive system response to

Definition
specific food certain foods

Immune system identifies food as Body cannot properly digest or

Cause
harmful process the food

Usually immediate (within minutes to Often delayed (several hours after

Onset
2 hours) eating)

Even a tiny amount can trigger a

Amount of Food Small amounts may be tolerated
reaction

Common Hives, swelling, itching, anaphylaxis, Bloating, gas, diarrhea, stomach

Feature Food Allergy Food Intolerance

Symptoms breathing issues cramps

Severity Can be life-threatening Usually not life-threatening

Diagnosis Blood tests, skin prick tests Elimination diet, food challenge

Avoidance, emergency medication Avoidance, enzyme supplements

Treatment
(e.g., epinephrine) (e.g., lactase)

Lactose intolerance, gluten

Examples Peanut allergy, shellfish allergy
intolerance (non-celiac)

Two Categories of Food Allergies (Types of Reactions):

• Immunoglobulin E (IgE) mediated. Symptoms result from the body’s immune
system making antibodies called Immunoglobulin E (IgE) antibodies. These IgE
antibodies react with a certain food.
• Non-IgE mediated. Other parts of the body’s immune system react to a certain food.
This reaction causes symptoms, but does not involve an IgE antibody. Someone can
have both IgE mediated and non-IgE mediated food allergies.
1. IgE Mediated Food Allergies
• The IgE mediated food allergies most common in infants and children are eggs, milk,
peanuts, tree nuts, soy and wheat.
• The allergic reaction can involve the skin, mouth, eyes, lungs, heart, gut and brain.
Some of the symptoms can include:
 Skin rash, itching, hives
 Swelling of the lips, tongue or throat
 Shortness of breath, trouble breathing, wheezing
 Stomach pain, vomiting, diarrhea
 Feeling like something awful is about to happen

 Sometimes allergy symptoms are mild. Other times they can be severe.
 Mild and severe symptoms can lead to a serious allergic reaction called anaphylaxis
(A severe, potentially life-threatening allergic reaction).
 This reaction usually involves more than one part of the body and can get worse fast.
 Anaphylaxis must be treated right away to provide the best chance for improvement
and prevent serious, potentially life-threatening complications.
2. Non-IgE Mediated Food Allergies:
 Most symptoms of non-IgE mediated food allergies involve the digestive tract.
 Symptoms may be vomiting and diarrhea.
 The symptoms can take longer to develop and may last longer than IgE mediated
allergy symptoms.
 Sometimes, a reaction to a food allergen occurs up 3 days after eating the food
allergen.

Treatment of Food Allergy: The Role of Nutrition in the Growth and Functioning of the
Immune System
• Allergy results when there is a breakdown in normal “tolerance” mechanisms, which
leads to inappropriate and detrimental immune responses to normally harmless
substances, including food allergens such as cow’s milk protein, eggs, nuts, or
shellfish.
• At birth, the immune system is immature, but it develops with age, antigen
stimulation, and appropriate nutrition.
• In addition, bacterial colonization occurs during the first weeks of life, and
interactions between intestinal flora and the developing mucosa result in further
development of immune responses and oral tolerance.
• Nutrition plays a key role in the development, maintenance, and optimal functioning
of immune cells.
• Nutrients, such as zinc and vitamin D and nutritional factors, such as pre- and
probiotics, can influence the nature of an immune response and are important in
ensuring appropriate functioning of the immune system.

1. FAT
• The role of fat on the immune system can be divided into the role of saturated vs.
unsaturated fats and the particular role of the essential fatty acids.
Saturated vs. Unsaturated Fats
• Diets rich in protein and saturated fat and low in complex carbohydrates may
negatively affect the diversity of the gut micro biome.
• The amount, type (e.g., unsaturated vs saturated), and mixture of dietary fats can
dramatically shift gut microbial community membership and function.
 Essential Fatty Acids (EFAs)
 EFAs are important immune regulators.
 Linoleic acid (LA), the parental n-6 polyunsaturated fatty acid (PUFA), is converted
into arachidonic acid (AA) by fatty acid elongase and desaturase, and subsequently
may give origin to pro-inflammatory and pro-allergic lipid mediators, whose
collective name is eicosanoids.
 Essential fatty acids (EFA) promote the renewal of the protective hydrolipidic film
layer of the skin.
 EFA deficiency may range from mild skin irritation to life-threatening conditions.

2. Zinc
• Children with food hypersensitivity have increased amounts of mastocytes,
eosinophils and neutrophils in the digestive tract.
• Persistent exposure to allergen can lead to chronic inflammatory changes of mucous
membrane and increased production of reactive oxygen species (ROS).
• Excess ROS should be neutralized by components of the antioxidative barrier.
• Therefore, all disturbances of enzymatic and non-enzymatic mechanisms of this
barrier lead to many unfavorable reactions, including oxidation of cell membrane
lipids.
• Zinc is an essential trace element and it is needed for various cellular functions;
specifically, it is a cofactor of many enzymes, including superoxide dismutase (SOD),
which play an important role in maintaining the oxidative-antioxidative balance.
• Children with food allergy have significantly lower concentrations of zinc, and
therefore a weakened antioxidative barrier.

3. Vitamin D
• The classical role of Vitamin D is, in fact, related to calcium homeostasis and bone
health.
• The active form of the vitamin, i.e., 1,25(OH)2D (calcitriol), has effects on epithelial
cells, T cells, B cells, macrophages and dendritic cells.
• It stimulates innate immune responses by enhancing the chemotactic and
phagocytotic responses of macrophages, as well as the production of antimicrobial
proteins such as cathelicidin.
• This action plays a role in maintaining mucosal integrity by stimulating junction
genes.
 • Almost all cells of the adaptive immune system express the vitamin D receptor,
making them also capable of being vitamin responsive.
• When specifically considering a potential role for vitamins in food allergy, vitamin D
has been shown to affect several mechanisms that promote immunologic tolerance.
That includes –
1. T regulatory cell function (suppress immune response, thereby maintaining
homeostasis and self-tolerance) and
2. The induction of tolerogenic dendritic cells (heterogenous pool of dendritic cells
with immuno-suppressive properties).

What is a food intolerance?

• Food intolerance, also known as non-IgE mediated food hypersensitivity or non-
allergic food hypersensitivity, refers to difficulty in digesting certain foods.
• It is important to note that food intolerance is different from food allergy.
• Food allergies trigger the immune system, while food intolerance does not.
• Some people suffer digestive problems after eating certain foods, even though their
immune system has not reacted - there is no histamine response.
• Foods most commonly associated with food intolerance include dairy products, grains
that contain gluten, and foods that cause intestinal gas buildup, such as beans and
cabbage.
• Symptoms of food intolerance tend to take longer to appear than symptoms of
allergies.
• The symptoms are varied and can include, migraine, cough, and stomachache.
• Some food intolerance is caused by the lack of a particular enzyme.

Symptoms
• When it is an allergy, even small amounts result in symptoms, as may be the case with
peanuts. Whereas, with food intolerance, tiny amounts will usually have no effect.
• The symptoms of food intolerance generally take longer to emerge, compared to food
allergies.
• Onset typically occurs several hours after ingesting the offending food or compound
and may persist for several hours or days.
• In some cases, symptoms may take 48 hours to arrive.
 • Some people are intolerant to several groups of foods, making it harder for doctors to
determine whether it might be a chronic illness or food intolerance.
• Identifying which foods are the culprits can take a long time.

The following are the most common symptoms of food intolerance:

• Bloating
• Migraines
• Headaches
• Cough
• Runny nose
• Feeling under the weather
• Stomach ache
• Irritable bowel
• Hives

FOOD AS ALLERGENS, THEIR SYMPTOMS AND DIAGNOSIS

Food Allergens:
The most common food allergens are milk, eggs, fish, shellfish, tree nuts, peanuts, wheat,
soybeans, and sesame. These foods account for 90% of food allergic reactions. Common food
allergens
 Milk - A common childhood allergy that affects 2–3% of babies and toddlers.
 Eggs - The second most common cause of food allergy in children.
 Peanuts, tree nuts, fish, and shellfish - Commonly cause the most severe reactions.
 Wheat - Most common in children and is usually outgrown before adulthood.
 Sesame - Declared a major food allergen in 2021.
Examples of Most Common Symptoms During Food Allergy, due to above mentioned
food allergens:

Cutaneous Gastrointestinal Respiratory

Erythema Nausea Nasal Congestion

Pruritus Abdominal pain Rhinorrhea
Urticaria Reflux Sneezing
Morbilliform Vomiting Hoarseness
rash Diarrhea Laryngeal Edema
Angioedema Cough
Eczematous Chest tightness
rash (typical of Dyspnea
late reactions) Wheezing
Increased work of breathing

FOOD ALLERGY DIAGNOSIS

1. Medical history — During a medical history, the clinician will ask questions about
our past reactions to food, such as:
• What symptoms a person has?
• What particular food do he/she think caused the reaction? Had he/she eaten this food
before? If yes, how often he/she eating it, when did he/she last eat it, and had he/she
eaten the food without having a reaction?
• How much time passed between eating the food and the first symptoms?
• Did he/she exercise or do other physical activity after eating?
• These questions will help the clinician to determine if a food allergy might be likely
as well as the type of food allergy that might be involved.
• Confirming classic food allergy often involves allergy testing.
• The clinician may decide to order blood tests.
• In other cases, they will refer to a specialist (such as an allergist or gastroenterologist)
for further evaluation.

2. Allergy testing —
• Testing for classic food allergy often includes skin testing and/or blood tests to
determine if IgE to the food is present.
 • Depending upon the situation, testing may also be done to determine if a person is
allergic to pollens, insects, latex, and other allergens.
• However, allergy testing is only recommended if the person is suspected to have a
food allergy.
3. Skin testing —
• Skin testing is involves pricking/scratching the skin with a tiny device that is coated
with food extract or fresh food.
• It is done by a trained clinician (usually an allergy specialist) and can be done on both
adults and children.
• The pricks are usually done on the forearm or upper back after the skin is cleaned
with alcohol.
• This should not be very painful, and any mild discomfort should resolve quickly.
• Fifteen minutes after the testing is applied, an itchy bump (hive) may form where the
skin was pricked, indicating if IgE is present.
• The size of the bump will be measured and recorded.
4. Blood tests —
• Blood tests are another way to determine if a person has IgE antibodies to certain
foods in their system.
• Different than skin testing, which provides results immediately after testing, blood
tests typically require several days to be completed.
5. Food diary —
• Clinician may suggest keeping a complete record of everything a person eat over a
period of time, including all foods, drinks, condiments, and candies.
6. Elimination diets —
• An elimination diet is a specially designed diet that removes one or more foods or
groups of food from a person's diet as part of the process of determining if a person
has food allergies.
• After a predetermined amount of time, the food is then added back to see if signs or
symptoms of an allergy develop.
• As with other forms of allergy testing, an elimination diet by itself does not often lead
to the diagnosis of food allergy and should be interpreted in combination with the
patient's history.