A Little Bit Can Hurt (16 page)

A:
It's an enormous responsibility because they need to know how to avoid what they are allergic to, which for some foods is relatively easy and others is incredibly difficult, and that is particularly related to foods that are from restaurants or places where you don't have access to food labels. Food labels are generally quite good, especially for the most common food allergens. The labeling law requires that they be accurately labeled in unambiguous language. The food-allergic patient needs to be very compliant with having their medications on hand because what we've learned more than anything else is that you can never plan a reaction. It will happen when you least expect it. Accidents are never planned, and there are enough ways that these common foods may make it into an ingredient or something where you don't expect that you have to have medication to deal with that one hundred percent of the time.

Q: Please describe immunotherapy for the treatment of food allergies.

A:
Immunotherapy is a general term in allergy that refers to gradually exposing the person to what they're allergic to. The most common form of immunotherapy is allergy shots for environmental allergens. Just this year, 2012, allergy shots hit their one hundredth anniversary, so they have been around a long time. When allergy shots were tried for food allergy, it turned out that the reactions at first were too severe to think of going that route. So what has happened over the last twenty years is trying to design ways to give foods to highly allergic people in a way that could be tolerated without too much risk.

There are two main avenues under study, one called
oral immunotherapy
where you're actually eating a powdered form of the food on a gradually increasing basis, and then
sublingual immunotherapy
where it's a liquid form given as a drop under the tongue. Right now oral immunotherapy looks far more promising than sublingual immunotherapy. And there are many, many other approaches under investigation right now, so it's likely that what we're doing in twenty years won't actually even look like what we're doing today. But right now the oral immunotherapy where, again, you're eating gradually increasing amounts of the food you're allergic to in a very controlled protocol seems to build up the most tolerance and potential to cure the food allergy.

Q: What is allergic eosinophilic gastroenteritis and how does it differ from food allergy?

A:
Allergic eosinophilic gastroenteritis is a condition where there is an allergic-type inflammation in the gastrointestinal tract. That is a very broad term. It is more usual for the eosinophilic inflammation to be present in just localized areas of the GI tract, the most common being in the esophagus, where the condition is called eosinophilic esophagitis. When you look at patients with eosinophilic esophagitis or eosinophilic gastrointestinal disease, the majority of them do have food allergies as an underlying cause, so in that sense it is a form of food allergy for many patients.

There are some patients, though, who have this allergic-type inflammation where you cannot identify the specific food allergy causing it. That possibility varies quite a bit with age, so that very young children usually do have a food allergy causing it. When you get into older children or adults, there is a lesser chance that a food allergy is the cause of it. But the first thought when someone has
eosinophilic inflammation anywhere in the GI tract is that it is likely to be a food allergy until you prove otherwise.

Q: And if it is not a food allergy, what would be the cause then? Is that when you use steroids?

A:
Yes. So in esophagitis, we think that environmental allergens can play a prominent role, and lower in the GI tract, environmental allergens are probably not getting there at all. It is not clear what's driving it. But we sort of liken it to patients with asthma where about three-quarters of the time you can identify environmental allergens that are causing the asthma, but in twenty-five percent of asthmatics, there is no allergy whatsoever. So it is something else in the immune system that is leading. In asthma, you have the same eosinophilic inflammation in the bronchial tubes as you have in the GI tract with patients with eosinophilic GI disease. So we're used to the fact that in allergy you can't always identify the offending allergen and may need to use medications, such as steroids, to control the inflammation.

Q: Is there promising food allergy research currently underway? Is it reasonable to hope for a food allergy cure?

A:
There is very promising research and a very good chance that there will be treatments for these most common food allergens. Whether it will be a complete cure or not is still under investigation. The time course of this, if things went really, really well, would be from now in 2012 to seven or eight years away. If things go a little bit more slowly, which can often happen in medical research, we're talking ten to twenty years.

But there has been so much progress in the last five years and there definitely are children in our studies who have been cured of very severe food allergies that we know it is possible. We know there is a lot of work to do to figure out the best and safest way to do it, but we do know that it's possible.

Chapter 18

ANN R. CALDWELL, RD, LDN

Title: Nutrition Services Coordinator, Anne Arundel Medical Center

Question: What is the difference between a registered dietician and a certified nutritionist?

Answer:
A registered dietitian is a food and nutrition expert who has met the minimum academic and professional requirements to qualify for the Academy of Nutrition and Dietetics credentialing as a "R.D." The majority of RDs work in the treatment and prevention of disease, in hospitals, HMOs, private practice or other healthcare facilities. In addition, a large number of RDs work in community and public health settings, academia and research. A growing number work in the food and nutrition industry, business, journalism, sports nutrition and corporate wellness programs. RDs often call themselves nutritionists, but not all nutritionists meet the requirements for RD credentialing.

Q: What is your role as a registered dietician?

A: I translate science into everyday information about food. I work with individuals to identify nutrition problems, assess their nutritional status and help them optimize their nutritional health. I encourage families to focus on "what can I eat" instead of "what can't I have." This positive focus helps individuals of
all ages. I do not suggest that food allergies take a back seat, but I encourage parents to focus on what their child can eat instead of what foods need to be eliminated. Nutritionists are experts at motivational interviewing and helping clients set their own goals for improving nutritional health.

Q: How does a food-allergic family know if they need to consult a dietician? How should they prepare for the first appointment and what should they expect during that visit?

A:
Often families are referred to the RD by their physician or healthcare provider. In some cases families realize the help of a professional will take the food issue/battle out of the parent-child arena and put it in the lap of the nutritionist.

I ask families to keep a detailed food log of three to five days before they come to see me. It gives us a place to start the dialog. It gives me a quick snapshot of the family's fueling patterns including foods that the child likes and doesn't like, and it helps me ask the right questions to drill down to obtain specific information. This is where I start regardless of why I'm seeing somebody.

So to prepare for the first appointment, for three to five days write down everything that you eat and drink so we can take a look at that, the time pattern and the amount of food/beverages. Be sure to include exercise! The simple act of logging food/beverage brings an awareness of intake that is impossible to obtain without this focus.

I use a computer program to analyze seven to nine days of food logs. This enables me to pinpoint nutritional issues and set realistic goals. For example, I can see in black and white what percentage of calcium the child is getting. The computer program helps me determine not just whether the growing child is getting enough protein, fat and carbohydrates but also whether he or she is taking in sufficient minerals and vitamins.

Q: How may a food-allergic family or individual find a reputable dietician if their family doctor or allergist is unable to provide a recommendation or referral?

A:
The Academy of Nutrition and Dietetics is the best place to find a reputable dietitian. The web site,
www.eatright.org
, has a link called "Find a Dietitian." You put in your zip code and obtain a list of RDs in your area. The list will include contact information and the RD's area of expertise.

Q: Nutritional deficiency is among the top concerns of parents of food-allergic children. Regarding each of the most common food allergies in children (milk, egg, peanut, tree nut, fish, shellfish, soy, wheat), what specific nutritional deficiencies pose a threat to good health? What substitutions or supplementations can be made to help provide adequate nutrition?

A:
Managing one food allergy is much easier for children than having to manage multiple food allergies. That's where a dietitian can help families map out a plan. In some cases, families living with food allergies do a better job of meeting nutritional needs because they must be great at reading food labels and planning for meals and snacks.

One of the most common allergenic foods for children is
milk.
During peak growing years, milk provides a good source of many nutrients needed for bone mineralization and growth. These nutrients include protein, calcium, vitamin D, vitamin A, vitamin B12, riboflavin and phosphorus. Selecting food substitutes to meet these nutrient needs is vital. Protein needs can easily be met with meat, poultry, fish, nuts and legumes. However, in order to obtain calcium, children need to eat a ton of non-dairy food sources of the nutrient and most can't meet the need. Parents need to read food labels to seek out calcium-fortified foods. Fortified juices can help with additional calcium but are not a good source of other nutrients. In some cases, supplements may be needed. In young children drinking milk-free formulas, this concern isn't an issue. Fortified soy, rice, grain (oat) and nut (almond) milks can also be considered but need to be fortified with additional nutrients.

Egg-allergic children must avoid whole
egg
in all forms. Eggs provide a source of quality protein. Eggs also offer iron, biotin, folacin, riboflavin, selenium and vitamins A, D, E and B12. Children generally get enough protein from other food sources. Selenium and B12 are obtained from meat. Folacin can be found in legumes, leafy green vegetables and fruits. If the child is eating a wide variety of non-egg foods, the egg-free diet should not place a child at nutritional risk.

Soybeans
do provide high quality protein in our diets. They contain thiamin, riboflavin, iron, phosphorus, magnesium calcium, zinc and vitamin B6. Restricting soy in a child's diet will not result in nutritional risk because these
nutrients can be obtained through other food sources. The real issue for families is avoiding soy products because they are found in so many of our processed foods.

Wheat
is the grain that has been most reported to trigger allergies. Grains contain protein and, as they are fortified, provide a great source of B vitamins and iron. Other grains such as corn, rice, barley, buckwheat and oats can be substituted, but you need to make sure they are from reputable sources and are fortified and enriched. A serving or two of an enriched fortified grain at each meal will help meet important nutrient needs for B vitamins, iron and folacin. Families incorporating a variety of grains enhance the meals for everyone in the family.

With regard to
tree nuts and peanuts,
the trace minerals, manganese, magnesium, chromium, copper and biotin are important but are easily obtained in a child's diet from other food sources. Peanuts and tree nuts are also very rich in protein, but again, this nutrient is abundant in other food choices. Vitamin E and B6 are also easy to obtain in diets providing a variety of foods.

If
fish and shellfish
must be avoided, you can find the same nutrients in other protein sources including meats, poultry, grains and legumes. In addition to protein, niacin, vitamins A and E, phosphorus, selenium, magnesium, zinc and iron are also found in fish and shellfish. These nutrient needs can easily be met by eating a well-balanced diet without fish or shellfish.

Q: What health problems and/or developmental delays stem from these nutritional deficiencies?

A:
Several studies have demonstrated that children with food allergies have lower intake of total energy and macronutrients/micronutrients than children without food allergies. I have seen children with failure to thrive and/or deficiencies in specific nutrients in my practice. In general these nutritional issues can be overcome with nutrition education, planning and patience.

Q: What advice do you have for a parent who states that their child will only eat one food, for example, peanut butter?

A:
I encourage parents to be patient and don't assume just because your child doesn't like something today that they might not like it tomorrow. It takes many attempts at new foods for a child to finally accept the item. It may take ten to fifteen times before a new food is accepted. I am opposed to families that do "cafeteria catering" where they're cooking five separate meals for everybody. You
need to cook one meal for your family. Everybody needs to be encouraged to eat the meal that has been prepared. I suggest parents always have at least one food item at each meal that they know their children like. Don't present a meal with all new items. I also encourage families to go grocery shopping together, and when preparing meals, include everyone. Children like to be involved from the selection to the preparation of meals.