Research Report 
Food Allergy – An Experience
Protecting Food Allergic Consumers and Celiac Patients in India Requires Improvements in Diagnostic Accuracy, Patient Education, Food Handling and Labeling Practices
Goodman, Richard PhD1; Gupta, Ashok MD2; Mahesh, Padukurdu MD3; Singh, Anand B. PhD4; Komarla, Nagendra Prasad MD5; van Ree, Ronald PhD6; Mills, ENC PhD7; Taylor, Steve, PhD1.
1Food Allergy Research and Resource Program, University of Nebraska, Lincoln, NE, USA; 2Dept. of Pediatrics, SMS Medical College, Jaipur, India; 3Allergy, Asthma and Chest Centre, Mysore, India; 4Institiute of Genomics and Integrative Biology, Delhi University, New Delhi, India; 5Bangalore Allergy Centre, Bangalore, India; 6Manchester Medical School, Univ. of Manchester, Manchester, United Kingdom; 7Academic Medical Center, Amsterdam, The Netherlands
Background:
Claims of marked increases in the prevalence of food allergy (FA) and celiac disease (CD) are common in the US and EU and increasingly in India where little is known about food allergy. Studies suggest increasing trends, but often lack rigorous definition of symptoms and tests. Reliance on Skin Prick Tests (SPT) or specific IgE alone, without corroborating clinical histories may be misleading. Once diagnosed, patients with FA or CD must avoid eliciting foods, which requires accurate information of food ingredients.
Methods:
A screen of suspected pulse-allergic subjects by selected clinicians in New Delhi, Chandigarh and Mysore/Bangalore was followed by laboratory IgE-tests with pulse extracts. Case histories of FA and CD from a medical college Pediatric clinic in Jaipur were reviewed. A systematic home survey conducted in Bangalore and Mysore involved more than 60,000 subjects with questionnaires and detailed follow-up with serology and SPT as part of Europrevall. A non-scientific survey of Indian food recipes and ingredients was used to consider terminology.
Results:
Based on limited data, the perceived rate of FA and CD in India by patients and clinicians is highly variable. Lack of standardized criteria, low availability and high costs of quality SPT reagents and laboratory tests (for CD and FA) hinder accurate diagnosis. Diverse terms and recipes for foods in India increases complexity. Allergy to milk and eggs is relatively common as expected. Reports of allergy to unlikely sources (e.g. brinjal, fruits and rice) are common, but are likely due to intolerance or too reliance on SPT or specific IgE binding, without clear clinical histories, which can be misleading. Rare cases of severe anaphylaxis to Vigna sp. (blackgram, mung bean and cowpea) and groundnut were found.
Conclusions:
Preliminary evidence demonstrates that severe food allergy is present in India where dietary habits, production and use of packaged foods are changing rapidly. Based on experiences in other countries it seems appropriate to expand education and training programs for clinicians, encourage development of valid testing systems and gather reliable information to aid the food industry and government regulators develop methods to help the food industry protect FA and CD patients from unintended exposure.
Introduction
Individual countries are responsible for the safety of food consumed by their people. However, as food production and consumption patterns become more global, countries are working together through organizations such as the CODEX Alimentarius Commission and OECD to provide food safety guidelines that should enable expanding trade, with some level of safety assured. Laws and mechanisms of regulation differ in each country and it is important to harmonize across countries to protect all at-risk consumers.
Food allergy and celiac disease (CD) are often hard to accurately diagnose. Relatively few consumers are affected, but a few are at risk of severe life-threatening reactions that are acute (IgE mediated allergy) or chronic (CD). There are complex genetic factors that increase the likelihood of sensitivity, but also many complex environmental factors have great influence in controlling sensitization or tolerance, but they are not proven or highly predictive. Diet, vitamin intake, exposure and development airway allergy (pollen, molds and arthropods), intestinal microbiota, parasite exposure and various viral or bacterial infections are likely modulatory agents.
Specific proteins in allergenic foods and CD (grains) are not equal in sensitizing or eliciting properties. However, it is extremely difficult (because of relatively low prevalence and lack of standardized diagnostic procedures) to obtain accurate prevalence data for specific allergens or CD for specific grains. Data from various studies of North America (US and Canada), various European (EU) countries (primarily Western Europe), Japan and Australia show likely prevalence of COMMON food allergens:
Severe Reactions
| Allergen | Children | Adults |
| All foods (IgE) | 3 - 8% | 1 - 4% |
| Cow’s milk | 2.5% | 0.3% |
| Eggs | 1.5% | 0.2% |
| Peanut | ||
| (Ground nut) | 1% | 0.6% |
| Common tree | ||
| Nuts | 0.5% | 0.6% |
| Fish | 0.1% | 0.4% |
| Crustacean | ||
| Shellfish | 0.1% | 2% |
| Buckwheat | ||
| (Japan) | 0.2% | 0.2% |
| Soybean | 0.4% | 0.3% |
| Wheat | 0.3% | 0.3% |
| Sesame seed | 0.1% | 0.1% |
| Celiac | 0.5%-1.2% | 0.5% |
| Disease (Tcell) Glutens |
Celiac Disease:
Chronic, but can have rapid onset for some. Failure to thrive, retarded growth, chronic diarrhea, chronic constipation, vomiting to thrive, dermatitis herpetiformis, anemia, osteoporosis,
Allergy / Allergology Societies and Consumer Groups
Global and country specific clinical / research organizations (WAO, AAAAI, EAACI, ICAAAI) provide opportunities to share scientific and clinical information to improve diagnosis and aid in risk assessment for the individual and the population. However, for food allergy there is a growing need for consumer education and support.
Patient and family organizations in the US (e.g. Food Allergy and Anaphylaxis Network or FAAN; Food Allergy Initiative or FAI; which have now merged to form FARE) and EU (e.g. European Federation for Allergy and Airways Diseases Patients’ Associations or EFA, and country specific groups) have organized patient and family groups to help food allergic subjects learn to better manage risks by learning to avoid foods containing their specific allergens or CD eliciting grain. Dr. Ashok Gupta is organizing a consumer group in India (and there may be others), to help educate consumers and provide feedback to clinicians, food companies and the government. While food allergy and Celiac Disease are not widely recognized in India, the prevalence is likely growing and it is useful to foster broader understanding of issues for diagnosis and prevalence for both food-related diseases.
Allergy Reduces Tumour Risk
The 'burden' of allergy may be a little lighter than we thought – the suggestion that having allergies reduces the risk of contracting a certain type of brain cancer is getting stronger.
A new study, led by Dr. Judith Schwartzbaum, Associate Professor of Epidemiology at Ohio State University, and published in the Journal of the National Cancer Institute (USA), found the reduced risk of glioma is stronger in females, although men with certain allergies also have a reduced risk.
The glioblastomas (tumours) can suppress the immune system, which means they can grow. Studies of blood were taken from men and women decades before they were diagnosed with glioma. It was found that men and women whose blood had allergy antibodies were 50 per cent less likely to develop the disease than those without the allergy antibodies.
'Seeing this association so long before tumor diagnosis suggests that antibodies or some aspect of allergy is reducing tumor risk,' says Dr. Schwartzbaum. Schwartzbaum and colleagues were granted access to specimens from the Janus Serum Bank in Norway. The bank contains samples collected from citizens during their annual medical evaluations, or from volunteer blood donors for the last 40 years.
'It could be that in allergic people, higher levels of circulating antibodies amy stimulate the immune system, and that could lower the risk of glioma. Absence of allergy is the strongest risk factor identified so far for this brain tumour, and there is still more to understand about how this association works.'
Glioblastomas account for 60 per cent of adult tumours starting in the brain in the USA, affecting an estimated three in 100,000 people. Mortality is severely affected – fewer than 10 per cent of patients will live for five years after diagnosis with the disease.
Gender has major role in allergy
The genetic risk of a child having allergies doubles if the parent of the same sex is an allergy sufferer, new research has found. The research was published in the Journal of Allergy and Clinical Immunology and funded by the National Institute of Health in the US.
Professor Hasan Arshad, a consultant in allergy and immunology at Southampton General Hospital (UK) and the Chairman of allergy and immunology at the University of Southampoton, says allergies are not just hereditary, but are related to gender.
He says allergists have previously thought that the maternal influence was predominant in passing on allergies to their children. However, now they know that mothers pass the risk of allergies to their daughters, as do fathers to their sons. In the study, which was funded by the National Institute of Health in the US and published in the Journal of Allergy and Clinical Immunology, 1456 patients were studied from birth to age 23. It was found that girls were 50 per cent more likely to have asthma if their mothers had it, with the same applying to boys and their fathers. The findings were also replicated for eczema.
'In the past, studies looking at the effect of parental allergy on children have not split their samples according to the sex of the child, having assumed the mother and father influence is identical in males and females,' said Professor Arshad.
'Now with these groundbreaking findings, we should see a change in the way we assess a child's risk of disease, asking girls for the allergy history of their mother and boys for that of their father.' Professor Arshad said the findings may aid future research into the genetics of allergy and its prevention.
Tackling cow’s milk allergy
There are many alternatives available to replace the nutrients found in cow's milk.
Allergy to cow's milk is one of the most common-about one in 50 babies are affected. Fortunately, most will outgrow their allergy by the end of their childhood.
Symptoms of cow’s Milk Allergy
- Swelling of the lips, face or eyes
- Hives or welts on the skin (urticaria)
- Tingling or peppery taste in the mouth
- Wheezing
- Eczema
- Gastro symptoms such as diarrhea, reflux/vomiting
Most children will only experience mild symptoms but some can have a severe reaction – anaphylaxis – that can cause problems with swelling of the throat and breathing. You need to seek immediate medical attention if this happens.
Who does Milk Allergy Happen ?
Milk allergy occurs when the immune system recognizes the protein in milk as a foreign body, and therefore attacks it. It's really important if you suspect a milk allergy in your child that you get professional advice from a doctor experienced in diagnosing and treating allergies. Your GP or specialist will make a diagnosis based on the history of previous reactions. The allergy can be confirmed by skinprick tests and /or bloods tests to measure the allergy antibodies.
How to Manage a Dairy – Free Diet
If your child is eventually diagnosed with a milk allergy, you need to completely eliminate milk, dairy products and any foods with milk-containing ingredients from their diet.
However, milk is an important sources of energy, protein, fat, calcium, vitamins B12, B2 (Riboflavin) and vitamin A. These are all critical for growth and health. Calcium is important for developing and maintaining strong bones in children and adults. It is always a good idea to work with a dietitian to manage a dairy-free diet in growing children.
Breastfeeding
Sometimes a baby who is exclusively breastfed can develop an allergy to milk, which is passed on through the mother's breast milk. In this case, the mother can stop consuming cow's milk themselves, and this usually stops baby's allergic reaction. Again, check this with a dietitian.
Replacements for Cow's Milk
Hypoallergenic formula
When a baby is allergic to cow's milk, it may be necessary to consider a specialized infant formula. There are many types available and should be selected on the advice of your GP, specialist or dietitian.
Extensively hydrolysed formula (EHF)
The cow's milk proteins have been broken down by enzymes into very small particles called peptides.
Amino acid formula (AAF)
Amino acids are the simplest form of protein and very easy for the human body to digest.
Soy milk formula
Soy- based formula is not generally recommend for infants under six months of age with cow's milk allergy as there is a risk they may become sensitized to soy or will react to the soy protein. Soy formula may be considered for infants over six months of age who are not sensitized to soy and who have refused the hypoallergenic formula.
Partially hydrolysed formula (PHF)
Partially hydrolysed formula is not suitable for the treatment of cow's milk allergy as the cow's milk protein has been only partially broken down.
Goat's milk
These animal milks are not suitable for children or adults with cow's milk allergy as the proteins are very similar to those in cow's milk and most people will react to these, too.
Milk replacements after one year of age
Some children may need to keep drinking a hypoallergenic formula after they reach 12 months of age, but only under the supervision of a dietitian.
