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Непоносимост или алергия към храни Непоносимост или алергия към храниРазбирането на разликата е ключът към правилния избор на лабораторната диагностика, която да уточни причината за непоносимостта към храната и да се открие веществото, което не се понася. Това са чести състояния и заболявания, които попадат при лекари с различни медицински специалности - общопрактикуващи лекари, гастроентеролози, педиатри, алерголози, токсиколози. Причината е, че пациентът получава силно плашеща реакция, която го отвежда до лекар, който първо трябва да овладее симптомите и след това да се заеме с разгадаването на проблема, който е по-скоро лабиринт от изследвания, отколкото точно написан протокол за работа. Първо нека си уточним терминологиятаТерминът „непоносимост към храни” обхваща всички нежелани симптоми или заболявания, свързани с консумацията на определени хранителни продукти. Той не е синоним на „хранителна алергия”. Непоносимостта към храни може да няма нищо общо с алергичните реакции и да не подлежи на повлияване от анти-алергичните лечения или ограниченията в приема на дадени храни. Когато се подозира и се търси причина за непоносимостта към храни, освен че трябва да изключим токсичните реакции (хранително отравяне и др.), както и заболяванията на храносмилателната система свързани с анатомична или функционална причина (дивертикул, панкреатит и др.), за правилната диагноза на непоносимостта към храни първо трябва да се направи разлика между имунните и неиммуните реакции. Непоносимост към храниРеакциите, които не са алергични, всъщност представляват по-голямата част от всички нежелани реакции към храни. Те са резултат от недостиг на ензим, при който елементи от храната не се смилат адекватно. Могат да се дължат на нарушена функция на храносмилателната система, при която някои вещества се усвояват само частично. И в двата случая неусвоените вещества достигат до по-дълбоките участъци на тънките черва, натрупват се и се разграждат от бактериите живеещи там до продукти, които образуват газове или диария. Имунната система не играе роля в тези реакции на непоносимост. Сред европейското население най-често срещаните нарушения в храносмилането и абсорбцията на вещества са непоносимостите към лактоза, фруктоза и хистамин. Непоносимост към млякоВсички бозайници спират да произвеждат ензима лактаза и имат непоносимост към лактозата от млякото, след като престанат да бъдат кърмени. Човекът също е бил създаден така. Обаче, населението на Европа и по местата, където се е налагало да се хранят с млечни продукти, хората са придобили генни мутации, които позволяват ензимът да се произвежда и след „отбиването“. При около една четвърт от населението на Европа, обаче, тази мутация я няма и те не понасят млякото и млечните продукти, защото нямат необходимия ензим. Лактозата (млечна захар) е дизахарид, съдържащ се в много храни и обикновено се разгражда до компонентите си галактоза и глюкоза в тънкото черво от ензима лактаза. Само тези монозахаридни молекули могат да се абсорбират през стената на тънкото черво. При недостиг на ензима лактаза, лактозата не може да бъде разградена и не се абсорбира. Неразградената лактоза достига до дебелото черво, където ферментира от нормалната бактериална флора. Съответно непоносимостта към лактоза е следствие от недостиг на ензим и не бива да се бърка с млечна алергия, при която имунната система реагира на съставки в млякото. Как се диагностицира?Само генетичният тест може да разграничи видовете лактозна непоносимост. Тестът се препоръчва за потвърждение в случай на положителни резултати от обременяване с лактоза. Този тест е от голямо значение за лечението, защото при пациенти с липса на мутация, която помага за производство на лактаза, единствените възможни лечения са диета без лактоза, диета с ниско съдържание на лактоза или доживотен прием на препарати, съдържащи лактаза. Лаборатории Synevo предлагат този тест: BM26 Генетичен тест за лактозна нетолерантност 196.00 лв. Алергични реакции към храниПри алергичните реакции всички съставки на приетата храна могат да бъдат смлени и усвоени от организма, тоест хората си имат всички ензими и храносмилателната им система си е наред. Само че, определени вещества в храната, които са абсолютно безопасни, водят до активиране на имунната система срещу тях. Настъпващите нежелани възпалителни реакции приличат на онези при защита срещу микроби. Имунните реакции на непоносимост включват различните хранителни алергии и кръстосани реакции, автоимуно индуцираната цьолиакия и така наречените псевдоалергични реакции към хранителни добавки. Алергия от от 1-ви типПо принцип всяка храна може да бъде алерген. Животозастрашаващите системни реакции са типични за храни като яйца, соя, фъстъци, ядки, риба и ракообразни. Тези алергии от 1-ви тип се предизвикват от наличието в организма на специфични за храната антитела от класа на IgE. Тези антитела са свързани с определен тип клетки (мастоцити), които при контакт със съответния алерген, се активират и отделят веществото хистамин, както и други фактори на алергичното възпаление. Това се случва веднага след контакта с алергена. Ето защо при този тип алергия симптомите като сърбеж, подуване на устната кухина и гърлото, астма, повръщане и диария се проявяват в рамките на минути до няколко часа след консумация на храната (затова алергията е от бърз тип). При алергизирани пациенти симптомите се отключват от много малки количества от съответния алерген в храната. Как се диагностицира?Лабораторната диагностика на алергия от 1-ви тип се извършва с тестове за алерген-специфични IgE антитела в кръвта. Като антигени в процедурата за установяване на IgE се използват високо пречистени екстракти, получени от различни храни чрез изсушаване и концентриране. Synevo предлага количествено изследване на нива на IgE при стимулация на серума от пациента с над 800 алергена, по отделно или в комбинации от най-често срещаните алергени. Алергия от 4-ти типТози тип алергии се срещат по-често сред възрастни в сравнение с децата. При тях IgE антителата не играят основната роля, а имунните клетки Т-лимфоцити. Тези активирани лимфоцити стават свръх-чувствителни към определни белтъци в храната. Този тип алергични реакции може и да не могат да се свържат веднага с определена храна, тъй като симптомите много често се появяват след 24 до 48 часа от консумацията на храната, предизвикваща алергична реакция. Симптоматиката е доста разнообразна, но има типични стомашно-чревни симптоми придружени с екземата, и обострянето на болки в мускулите или ставите. Как се установява алергия от 4-ти тип?За установяването на алергия от 4-ти тип съществуват два независими метода: лимфоцитно трансформационен тест (LTT) и кожния тест. В някои случаи те се допълват добре, например при дерматологични заболявания от професионален характер. Основната разлика между двата метода е, че кожният тест е само за установяване на контактни алергии, т.е. алергии, при които сенсибилизацията е настъпила при контакт с кожата и които се проявяват върху кожата. Предизвикателство пред LTT теста е това, че кръвта трябва да достигне до лабораторията до 24 часа, а най-близката лаборатория е тази на Synevo в Берлин. Чрез използване на правилната куриерска услуга, това е напълно възможно поне един път седмично и съвсем скоро ще предложим това изследване за нуждаещите се пациенти от България. Непоносимост към хистаминТова не е алергия, но е честа причина за подобни симптоми. Състоянието е резултат от недостиг на ензима, който разгражда хистамина –веществото, което предизвиква част от симптомите при алергия. Ензимът се нарича диамин оксидаза (DAO). Липсата на DAO може да се дължи на първични (генетични) или вторични причини - изчерпване. В единият случай, човекът не произвежда ензима, а в другият организмът е обременен с толкова много хистамин, че независимо от нормалната си активност, ензимът DAO не може да го разгради адекватно. Излишъкът от хистамин може да бъде причинен от прием на храна с много хистамин или да се дължи на произведен от организма хистамин при възпаление, или алергия. Тестът, предлаган от Synevo: AL71 DAO (непоносимост към хистамина) 69.00 лв. Как се диагностицира хистаминова непоносимост?Много често лекарите назначават първо тестове за хистаминова непоносимост, за да изключат тази причина за алергични симптоми. Изследва се нивото в серума на DAO. Недостигът на DAO и повишените нива на хистамин могат да се установят с лабораторни тестове. Освен това може да се използва генетичен тест за разграничаване на първичния от вторичния недостиг на DAO. Synevo предлага всички тези изследвания. Псевдоалергии или непоносимост към хранителни добавкиХранителните добавки са оцветители, консерванти, антиоксиданти, желиращи агенти и сгъстители, овкусители и подсладители. Съвременните храни са пълни с тях. При индивидуална свръхчувствителност, някои от тези „Е” вещества или техни заместители могат да предизвикат псевдоалергични реакции и в редки случаи, дори реакции от първи (бърз) тип. Поради все по-широката им употреба в хранителната промишленост и нарастващия брой одобрени добавки честотата на нежеланите реакции се увеличава. Симптомите на този тип реакция на непоносимост наподобява алергична реакция от бърз тип с обриви, задушаване, спазъм на дихателните пътища, стомашно-чревни симптоми, екзема, главоболие. Само че, антителата от клас IgE не участват в процеса. Активацията на мастоцитите настъпва не заради свързване на IgE с алерген, а посредством пряко взаимодействие на веществото с клетката. Синдром на „пропускливите черва“Червата ни са покрити със слой клетки – епител, който има за цел да пропуска до кръвта определени вещества в определена степен и да не допуска преминаването на бактерии и по-големи молекули. Чревният епител е изложен всекидневно не само на компонентите на храните, а и на бактерии, дрожди, плесени и редица токсични вещества с потенциал да активират имунната система. При нарушаване на чревната бариера (пропускливи черва) изброените фактори, стимулиращи имунната функция, проникват по-лесно в граничните слоеве на лигавицата. Това води до увеличено проникване на алергени и колонизация на червото с несвойствени микроби. Така червата се превръщат в област на инфекция и в източник на възпаление. Симптомите наподобяват алергии и хранителна непоносимост. Ако този синдром не се вземе предвид, пациентът ще получи най-различни лечения и диети без особен ефект. Как се диагностицира?Зонулин – това е маркер за чревна пропускливост. Белтъкът зонулин регулира връзките между клетките, които покриват червата отвътре. Анализът на нивата на зонулин в серума позволява определянето на чревната пропускливост. Определянето на зонулините се използва за поставянето на диагноза в случай на „пропускливи черва”, а също и за проследяване на лечението при други заболявания, например при пациенти с цьолиакия нивата на зонулина намаляват успоредно с възпалението при спазване на строга безглутенова диета. Тестовете, които предлага SynevoSynevo предлага най-широката гама от лабораторни изследвания в областта на алергиите и хранителните непоносимости. Лабораторията ни в Берлин – IMD е един от водещите европейски центрове в тази област. Изследването на алергичните заболявания е една от областите на специализация на IMD. Извършват се изследвания във всички видове алергични реакции. Поради близкото сътрудничество с Phadia AB (Швеция) и Euroimmun (Германия), нивото на качество на тестовете за алергия тип 1 е едно от най-високите. Прилагат се тестове за над 800 алергена и специфичните им IgE антитела. Спектърът от изследвания се разрастна през последното десетилетие и включи тестове за имунни и псевдоалергични реакции към храни, лекарства и химически субстанции, чрез валидирани и сертфицирани тестове като тест за лимфобластна трансформация (LTT) и базофилна активация. Всички маркери отнасящи се за алергии, хистаминова непоносимост, цьолиакия и синдрома на пропускливите черва са налични в лабораторията.
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Lactose Intolerance Food Allergies Peanuts can leave you breathless. Cat dander can lead to itchy eyes, a stuffy nose, coughing and sneezing. And most of us have suffered through those seasonal allergies with horrible pollen counts. Learn more... How Tos for Coping with Food Allergies If you're diagnosed with a true food allergy, what's next There's no cure. You'll likely need to avoid the troublesome food and prepare and choose meals and snacks with care If you must eliminate a food, or a category of food, plan carefully to ensure that your eating plan is nutritionally adequate and fits your food preferences and lifestyle. Start by seeking professional help. A registered dietitian can help you learn to manage a food allergy while eating a varied and balanced diet. For example, ask about making food substitutions, reading food labels, and dining away from home. Ask about nutri . if chocolate really causes acne No chocolate doesn't cause acne or make acne worse. Hormones and hygiene, rather than a chocolate allergy, are more likely the culprits. A true food allergy to chocolate is rare. Instead, a reaction to a chocolate bar may come from other ingredients mixed in, such as nuts or milk. if foods modified by biotechnology contain allergens It's possible. Controversies Related to Food Allergies and Intolerances Controversial issues in this area include the diagnosis of brain allergy, the diagnosis of environmental illness related to food allergy, and the diagnosis of yeast allergy. The connection of these problems to food allergies is not universally recognized. Some have also linked hyperactivity to food allergy or intolerance. Hyperactivity in children, in some instances, may be related to eating large amounts of food additives, but it is not accepted to be an allergic condition by the majority of the scientific community. Other controversies relate to testing for food allergies. One controversial test is cytotoxic testing, which involves testing blood in the presence of the suspected food allergen to see if the blood cells are killed. Treating a True Food Allergy What's the treatment once you're diagnosed with a true food allergy Avoid the offending food Although this list is not a substitute for consulting a registered dietitian, it can provide a pretty good idea of which food ingredients to avoid after you've been diagnosed with one of the following food allergies For further information and a free newsletter on food allergies, send a self-addressed stamped envelope to The Food Allergy and Anaphylaxis (FAAN) 10400 Eaton Place, Suite 107 Fairfax, VA 22030 1-800-929-4040 www.foodallergy.org Some people have such severe food allergies that they can even exhibit symptoms from the following The Food Allergy and Anaphylaxis Network The Food Allergy and Anaphylaxis Network (FAAN) is a nonprofit membership organization (membership fee 30 year for individuals) whose participants include families, doctors, dietitians, nurses, support groups, and food manufacturers in the U.S., Canada, and Europe. The group provides education about food allergies in addition to support and coping strategies for people who are allergic to specific foods. This no-nonsense, highly accessible site is required reading for people with food allergies. Others, such as families and friends, can also benefit from its solid information and support services. Diagnosing a True Food Allergy Many folks view this whole food-sensitivity business as faddism and quackery, and unfortunately, we have earned this mindset. Did you know that out of the gazillions of people who think they have a food allergy, less than 2 percent of the American adult population actually have one Why does the idea of a food allergy get so recklessly thrown around One reason may be that people are often quick to blame physical ailments on food. Another aggravating reason for all the misdiagnoses are those so-called allergy quacks that grab your hard-earned money and diagnose you with the allergy of the month. In today's world, a true food allergy can be properly diagnosed with scientific sound testing. If you think you might suffer from an allergic response to certain foods, get it checked out. The first step is to find a qualified and reputable physician who has been certified by the American Board of Allergy and Immunology. Ask your primary doctor for a referral, or call the American Academy of... Food Allergy Clinical Presentation and Diagnosis Health problems associated with food allergies can involve the gastrointestinal system, the respiratory system, the skin, and the eyes. Persons with a food allergy may have difficulty breathing, or they may have problems with itching, rashes, swelling, nausea, or vomiting. A food allergy may also be a cause of asthma. The symptoms of food allergy vary widely from person to person. Food allergies can also cause a severe clinical reaction known as anaphylaxis, which can result in death. Anaphylaxis may be characterized by throat and lip swelling, shortness of breath, sweating, itching, and feeling very faint. Diagnosis of a food allergy usually involves a careful examination of the patient's symptom history. Other causes of symptoms must be ruled out, and in some instances the suspected food or foods will be eliminated from the diet to see if symptoms stop. Blood tests or skin tests may also be performed. One test sometimes used to diagnose food allergy is the doubleblind,... Understanding Food Allergies A true food allergy is a hypersensitive reaction that occurs when your immune system responds abnormally to harmless proteins in food. That is, your body misinterprets something good as an intruder and produces antibodies to halt the invasion. Remember the episode of Three's Company when Jack sneaked in late one night, and Chrissy and Janet mistook him for a robber and clobbered him over the head It's the same thing with food allergies, only you're the one who gets clobbered. Food allergy is an overreaction by the body's immune system, usually triggered by protein-containing foods (such as cow's milk, nuts, soybeans, shellfish, eggs, and wheat). Food intolerance is an adverse reaction that generally does not involve the immune system (such as lactose intolerance). Food allergies classification Differentiation between IgE-mediated and non-IgE-mediated reactions may therefore be difficult. The Melbourne Milk Allergy Study, conducted by Hill and colleagues,17 identified three types of reaction in sensitized children - immediate reactions (rapid skin reactions with perioral erythema, facial angioedema and urticaria, some developing anaphylaxis), intermediate reactions (gastrointestinal symptoms such as vomiting or diarrhea occurring 1-24 h after ingestion) and delayed reactions (eczema flares or respiratory symptoms such as cough and wheeze, occurring between 1 and 5 days after challenge). The volume of milk required This occurs within minutes of exposure, as seen in quick-onset food allergy. The allergen binds to, and cross-links IgE (occasionally IgG1) on the mast cell surface, inducing its degranulation and release of vasoactive agents (histamine, tryptase, etc.) and cytokines (tumor necrosis factor-a). Responses to some antigens (classically peanut) are usually of this... Food Allergies What Are They A true food allergy, sometimes called food hypersensitivity, causes the body's immune system to react even though the person isn't sick. The body reacts to a usually harmless food substance, thinking it's harmful. An allergen, usually a protein in the troublesome food, sets off a chain of immune system reactions. When an allergy-prone person eats a food that causes an allergic reaction, his or her body scrambles to protect itself by making immunoglubulin E (IgE) antibodies. These antibodies trigger the release of body chemicals such as histamine. In turn, these body chemicals cause uncomfortable symptoms associated with allergies, such as a runny nose, itchy skin, nausea, even a rapid heartbeat, or in severe cases, anaphylaxis. What are the symptoms of a food allergy Different people react to the same allergen in different ways. Even if a food contains a common allergen, you can't predict whether you may have an allergic reaction. Symptoms may appear within seconds or up to several... How Do Food Allergies Develop There are a couple of theories for how food allergies develop. One involves exposure to partially digestive proteins in early life. Although the digestive tract is rapidly developing during the first few months of infancy, there remains the potential for complete or semicomplete food proteins to cross the wall of the digestive tract and enter the body. When this occurs, an infant's immune system recognizes this substance as foreign and destroys it. At the same time an infant develops immune memory of that substance for future reference. This immune memory includes a routine production of antibodies that specifically recognize that substance. These antibodies allow the body to develop a very rapid and potent immune response when exposed to that substance again in the future. This response causes the release of chemicals in the body (for example, histamine and serotonin), which may cause any number of the following actions itchiness, swelling, vomiting, asthma, diarrhea, headache, skin... Specific food allergies There are no consistent associations between any particular food and specific syndromes, although some foods are more likely than others to induce enteropathy, such as cow's milk and soy, and others usually induce immediate hypersensitivity, such as peanut. The incidence of gastrointestinal food allergy is greatest in early life and appears to decrease with age. However, analogy with celiac disease, in which late-onset enteropathy is more likely to be clinically subtle, suggests that the increase in colonic salvage that occurs with age may mask true food-sensitive enteropathy. Although enteropathy can cause significant failure to thrive, complex multiple allergies may also occur in the presence of normal growth.5 Cow's milk allergy may commonly present either as an immediate response, including anaphylaxis, or with delayed responses within the gut or skin. CMSE was frequently diagnosed in the past because of failure to thrive following an episode of gastroenteritis,97 and the... What Are Food Allergies Food allergies are immune responses to food components. Six to eight percent of children have food allergies and two percent of adults have them. The most common food allergies in adults are shellfish, peanuts, tree nuts, sesame seeds, fish, and eggs, and the most common food allergies present in children are milk, eggs, and peanuts. Signs and symptoms of food allergies include swelling of lips, tongue, and airway (wheezing), itching, hives, eczema and, if severe enough, anaphylaxis. Since there is no cure for food allergies at this time, the allergic person has to avoid any and all forms of the food to which they are allergic. Food Allergies Less Common Have you ever heard parents say that their child is allergic to milk, then remark that he or she has no adverse reactions to chocolate milk Or maybe you avoid a particular food yourself, believing you have an allergy to it Although food allergies are not to be taken lightly, you may be surprised at just how infrequently true food allergies occur. Consider that One in three adults believes that he or she is allergic to milk. However, reports the National Institutes of Health (NIH), only 4 percent of Americans are estimated to have food allergies. About 11 million Americans overall have food allergies 6.5 million with seafood allergies, 3 million with peanut and tree nut allergies. In recent years the prevalence of food allergy has gone up. Food Intolerances and Other Adverse Food Reactions If your body reacts to food or a food component, you may have a food intolerance, not an allergy. Unlike food allergies, food intolerances don't involve the immune system. Because they prompt many of the same symptoms (nausea, diarrhea, abdominal cramps) food intolerances are often mislabeled as allergies. With a food intolerance, physical reactions to a food often result from faulty metabolism. The body can't adequately digest a certain component of a particular food perhaps because a digestive enzyme is deficient. Substances that are part of a food's natural chemistry such as theobromine in coffee or tea, or serotonin in bananas or tomatoes may cause reactions, too. Depending on the type of food intolerance, most people can eat small servings of the problem food without unpleasant side effects. (People with gluten intolerance and those with sulfite sensitivity are exceptions.) In contrast, people with food allergies usually need to eliminate the problem food from their diet. Common Foods Associated with Food Allergy Almost any food can cause an allergy, though the foods most commonly associated with an allergic reaction are those frequently consumed by a population. For example, an allergy to rice is common in Southeast Asia, while fish allergy is a problem in the Scandinavian countries, where fish is frequently consumed (even at breakfast). Age is also a factor influencing the types of foods to which a person might be allergic. In the United States, common foods to which adults are allergic include eggs, shrimp, lobster, peanuts, other nuts, and fish. U.S. children who have food allergies find their problems are most frequently linked to milk, soy, eggs, and peanuts. Infants may be allergic to cow's milk or soy formulas. Some food allergies may be outgrown, but allergies to peanuts, shrimp, and fish tend to last throughout life. In addition, some individuals are only allergic to one food, whereas some are allergic to several foods. An allergic reaction can be triggered by a very small amount of... Whats Lactose Intolerance All About If you can't stomach milk and you experience bloating, nausea, cramping, excessive gas, or a bad case of the runs after eating a dairy food, you are not alone. In fact, an estimated 30 to 50 million Americans suffer from some degree of lactose intolerance, which is the inability to digest the milk sugar lactose. In fact, I once had a client tell me he visited so many restrooms while touring through Europe he was ready to write The Complete Idiot's Guide to European Bathrooms. Up to 70 percent of the entire world's population does not produce enough of the enzyme lactase and therefore has some degree of lactose intolerance. In the United States alone, the following groups experience some or all symptoms of lactose intolerance Don't confuse a lactose intolerance with a milk allergy. A lactose intolerance involves difficulty digesting the milk sugar lactose a milk allergy involves an allergic reaction from the protein components in cow's milk. Folks who suffer from milk allergies cannot... Types of Lactose Intolerance There are three basic types of lactose intolerance primary, secondary, and congenital. In primary lactose intolerance, the body begins to produce less lactase after about the age of two, depending on an individual's racial or ethnic background. This type is genetically determined and is a permanent condition. Secondary lactose intolerance, on the other hand, is temporary and results from a disease or medications that damage the lining of the small intestine where lactase is normally active. Secondary lactose intolerance gradually disappears when the illness passes. Congenital lactose intolerance is an extremely rare condition in which the lactase enzyme is completely absent at birth. Unlike other types of lactose intolerance, this type requires complete avoidance of lactose. For Those with Lactose Intolerance Another Option As another option, food products have been developed for people with lactose intolerance. Some products are lactose-reduced. Others contain lactase, the enzyme that digests milk sugar and that's deficient to some degree in people with lactose intolerance. If you're lactose-intolerant and if Lactose Tips for Tolerance in this chapter aren't enough If you're lactose-intolerant, consult a registered dietitian (RD) to help you plan a diet, adequate in calcium and vitamin D, while controlling the lactose in your meals and snacks. In extreme cases or for children or pregnant women with lactose intolerance, a physician or a registered dietitian also may recommend a calcium supplement. Most older children and adults can eat some foods with lactose, in some amount. For infants and young children, talk to your doctor about lactose-containing foods. Lactose intolerance is easy to manage. Most people with difficulty digesting lactose can include some dairy and other lactose-containing foods in... What Is Lactose Intolerance By early childhood much of the world population, especially people of African, Asian, and Greek descent, loses the ability to produce sufficient amounts of the digestive enzyme lactase. In fact, lactase production decreases an average of 90 percent by age five, resulting in poor lactose digestion. This is believed to be the natural course for humans and a similar situation can be seen in many other mammal species after they wean from their mother's milk. However, in some populations such as Swedes, Finns and Caucasians in United States, the incidence of lactose intolerance is low (< 12 percent). It is believed that this is the result of genetic change that occurred long ago, which minimized the reduction in lactase production, resulting in this trait today. the small intestine into the colon where it becomes available to bacteria. Bacteria easily break down lactose for energy and produce gases such as hydrogen gas (H2) and carbon dioxide (CO2) and other substances in the process.... Food Intolerance Clinical Presentation and Diagnosis Health problems caused by food intolerance vary depending upon the food and chemical involved. The amount of a food eaten may also play a role. Lactose intolerance is usually characterized by gastrointestinal problems such as bloating and diarrhea. Sulfite intolerance is typically characterized by difficulty in breathing. Those sensitive to MSG may experience a variety of symptoms, such as headache, numbness, and rapid heartbeat. Tyramine, found in pickled herring, soy sauce, red wine, and other foods, has been linked to migraine headache. Capsaicin can cause a burning pain in the mouth and other problems, such as nausea and vomiting. Myristicin has been associated with anxiety, chest pressure, hallucinations, fever, and skin redness. Diagnostic techniques for food intolerances vary depending upon the specific intolerance suspected. Symptom history and elimination diets are tools that are used, and the double-blind, placebo-controlled food challenge may also be helpful. Diagnosis of... Nutrition for People with Lactose Intolerance Milk and other dairy products are a major source of calcium. Many people with lactose intolerance may be able to tolerate yogurt with active cultures, which is very high in calcium, even though it is fairly high in lactose. Evidence shows that the bacterial cultures used in making yogurt However, people with lactose intolerance who do not drink milk or eat diary products can still get the calcium they need from dark-green, leafy vegetables such as broccoli, turnip or collard greens, and kale. Certain fish with soft, edible bones, such as herring, salmon, or sardines, are also good calcium sources. National Digestive Diseases Information Clearinghouse (2002). Lactose Intolerance. NIH Publication No. 02-2751. Available from Living with a Lactose Intolerance The following tips are helpful for people who have difficulty digesting lactose. As mentioned earlier, the degree of lactose intolerance can vary from person to person therefore, not everyone will be able to handle all of the suggestions. Give them each a shot, but be sure that you're in a comfortable place if some seem a bit risky. Keep in mind that lactose-containing foods are generally your best sources for the mineral calcium, so children and women with increased calcium requirements should load up on the nondairy sources and speak with a registered dietitian about the possibility of calcium supplementation. For further information and a free brochure on lactose intolerance, call 1-800-LACTAID. For further information and a free brochure on lactose intolerance, call 1-800-LACTAID. Some people with lactose intolerance can tolerate yogurt because the bacteria in the yogurt actually metabolizes the milk sugar lactose for you. Future challenges and opportunities in food allergy There have been substantial recent advances in the basic science of food allergies. There has been a broadening of the concepts of food allergy, away from simple focus on IgE and towards a consideration of overall mucosal tolerance. Could a genetic tendency to high IgE responses simply make adverse immunological reactions to foods more noticeable As many practitioners are uncomfortable without supporting diagnostic tests, non-IgE-mediated allergy may remain a difficult and controversial clinical area. Absence of specific tests can also lead to overdiagnosis of allergies, or inappropriate blaming of non-specific symptoms on food allergy - as can be seen on large numbers of Internet sites. There are other exciting potential therapies for food allergies, some of which have been subject to clinical trials in humans.172 The area of immunotherapy is well established for systemic allergies such as bee-sting allergy, and has depended on increasing the dose of antigen gradually until an... Testing for food allergies Food challenge testing The essential criterion for diagnosis of food allergy is a response to an elimination diet, and other diagnostic tests are secondary to this. If there is allergy to a single food, exclusion should induce relief of all symptoms, and restore normal growth. For secure diagnosis, a positive response to challenge with the food antigen is strongly supportive of the diagnosis of food allergy. This is not always practicable in routine practice, if diagnostic tests were positive at diagnosis, and many parents may refuse challenge if their child has improved dramatically. Insurance companies, however, may require evidence of positive food challenge for reimbursement. In children with multiple food allergies, the response to elimination of single antigens is incomplete, and lengthy assessment with a very restricted diet is often required. Such situations may become complicated, particularly since the advent of Internet sites that implicate food allergies in an unfeasibly broad spectrum of... Lactose Intolerance Because Amy has a form of lactose intolerance, she cannot digest milk unless it is in the form of yogurt, hard cheese, or cottage cheese. Drinking any milk products that contain lactose, such as the chocolate shake, will result in discomfort. Anyone with lactose intolerance should avoid milk, milk solids, whey (the liquid from milk), and casein, which is milk protein. Lactose is also found in breads, cereals, instant soups, instant potatoes, salad dressings, and nondairy powdered creamers. Drinking acidophilus milk or taking a pill containing lactase can also help avoid the digestive problems. In addition, about 20 of prescription drugs and 5 of over-the-counter drugs contain lactose. People with lactose intolerance need to be careful not to become deficient in calcium or riboflavin, a B vitamin. When Food Gives You Hives Revealing what a food allergy is Finding foods most likely to trigger allergic reactions Discovering whether you're allergic to a specific food Exploring differences between food allergy and food intolerance J ccording to the Food Allergy & Anaphylaxis Network (FAAN), at least W 11.4 million Americans have true food allergies (also known as food hypersensitivity) this number includes more children than adults because many childhood allergies seem to fade with age. So, you may ask, if allergies are likely to disappear, why do I need a whole chapter about them Good question. I have two good answers. First, food allergies that don't disappear can trigger reactions ranging from the trivial (a stuffy nose the day after you eat the food) to the truly dangerous (immediate respiratory failure). Second, a person with food allergies is likely to be allergic to other things, such as dust, pollen, or the family cat. And forewarned (about food allergies) is forearmed (against the rest), right... Have You Ever Wondered 111 what is an exercise-induced food allergy It's a reaction from eating a certain food before exercising. Allergic reactions may appear once exercising starts and the body temperature starts to rise. Anaphalaxis may even develop. The way to manage this avoid eating that food for a couple of hours before exercising. For more education about managing specific food allergies, and a cookbook, newsletters, and other support, contact the Food Allergy and Anaphylaxis Network. See Resources You Can Use at the back of this book for contact information. Testing Testing Identifying Food A llergies To identify the culprit causing your food allergy, your doctor may suggest an elimination diet. This regimen removes from your diet foods known to cause allergic reactions in many people. Then, one at a time, the foods are added back. If you react to one, bingo That's a clue to what triggers your immune response. Previous pagepagenext page Egger, J., Carter C.M., Wilson, J., Turner, M.W. and Soothill, J.F. (1983) Is migraine food allergy A doubleblind controlled trial of oligoantigenic diet treatment. Mansfield, L.E., Vaughn, T.R. and Waller, S.F. (1985) Food allergy and adult migraine, double-blind and mediator confirmation of an allergic etiology. Ann. Allergy. Monro, J., Brostoff, J., Carini, C. and Zilkha, K. (1980) Food allergy in migraine study of dietary exclusion and RAST. Lancet 2, 14. Have You Ever Wondered 109 if avoiding certain foods during pregnancy can prevent food allergies in the baby There's no conclusive evidence that restricting foods during pregnancy makes any difference. In fact, it's not recommended. Babies born to mothers who have restricted their diets during pregnancy often have lower birthweights. And eating a known food allergen during pregnancy won't cause a food allergy in the infant either. See Food Sensitivities and Your Baby in chapter 15 for more guidance. if breast-feeding can prevent food allergies in the baby Perhaps so. For those with a family history of allergies, breast-fed babies are less likely to have food allergies. As a precaution against potential allergens in breast milk, the American Academy of Pediatrics suggests that nursing mothers of susceptible infants (with a family history of allergies) are wise to skip peanuts and peanut-containing foods. See Breast-Feeding Your Baby in chapter 15 for more information. Warning If you or a family member... Have You Ever Wondered 110 You're allergic to eggs, you'd need to know that eggs are common ingredients in mayonnaise, many salad dressings, and ice cream. Food labels list the ingredients in the food inside the package. The chart Label Lingo Some Terms for Common Allergens in this chapter gives some ingredients to watch for on ingredient lists of food labels if you have a food allergy. If you have a milk or casein allergy, be cautious before choosing kosher foods labeled as pareve or parve. For religious purposes these foods are milkfree, or perhaps have only a very small amount of milk. Although appropriate for those with lactose intolerance, it may not be milk-free from a food science perspective or for those with food allergies. However, if a D appears next to the kosher symbol, it does have an ingredient derived from milk. DE means that it was produced in equipment shared with a dairy consider avoiding these foods, too. See chapter 11 for kosher symbols. Gastrointestinal function and disease The cause of IBS is unknown but it occurs in many patients following dysentery or antibiotic use. In addition, patients often volunteer that specific foods upset them (food intolerance) and stress is clearly contributory. Wheat bran and other bulk laxatives are frequently given, but results have been very variable. They may aggravate symptoms through gas production, although in patients who are predominantly constipated they are of benefit. Because of a postulated disturbance in the colonic microflora in IBS a number of groups are currently trying the use of probiotics to 'normalize' the flora. Food allergy (Isolauri, 1995) Food allergy is defined as an immunologically mediated adverse reaction against dietary antigens. Food allergy can affect several organ systems, the symptoms commonly arising from the gut, skin and respiratory tract. Despite the wide spectrum of clinical manifestations, there are at least two prerequisites for the development of food allergy dietary antigens... Recommendations for food allergen avoidance There remains controversy about the stringency of allergen avoidance required in food allergies, recently reviewed by Zeiger.115 Two position statements have been published, by the American Academy of Pediatrics (AAP)99 and a joint statement by the European Society for Pediatric Allergology and Clinical Immunology (ESPACI) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).116 These statements deal with two areas of importance the primary prevention of development of food allergies, and the treatment of the affected child. For treatment of established food allergies, both statements recommend complete exclusion of the causative antigen, and show broad consensus in the management of a formula-fed cow's milk-sensitized infant, with recommendation of an extensively hydrolyzed but not partially hydrolyzed formula. However, the AAP guidelines also suggest that soy is an alternative in this circumstance, which is not supported by the European... After dietary assessment recommend nutrient supplements for vegan diets which are found to be nutrit Adverse food reactions are divided into two general categories food intolerance and food hypersensitivity. An allergic reaction to a food involves the immunologic system. The incidence of food allergies has been estimated at 8 in the first year of life, and decreases as children get older however, most further qualify it to be in the 1 to 2 range (Bock, 1987). The risk of developing food allergies is largely related to genetic predisposition and the age at which the food is introduced, with the chance of sensitization greatest in the first year of life. Young infants are especially prone because their immature intestinal system is more permeable to absorption of food allergens and lacks local immune defences (Burks and Sampson, 1993). Most allergens are proteins of large molecular size, therefore food allergy commonly presents in infancy with the first introduction of milk, egg or peanut (Burks and Sampson, 1993). These three foods, as well as soy, nuts and wheat,... Concerns about Food Production Some concerns about the use of biotechnology for food production include possible allergic reactions to the transferred protein. For example, if a gene from Brazil nuts that produces an allergen were transferred to soybeans, an individual who is allergic to Brazil nuts might now also be allergic to soybeans. As a result, companies in the United States that develop genetically engineered foods must demonstrate to the U.S. Food and Drug Administration (FDA) that they did not transfer proteins that could result in food allergies. When, in fact, a company attempted to transfer a gene from Brazil nuts to soybeans, the company's tests revealed that they had transferred a gene for an allergen, and work on the project was halted. In 2000 a brand Specialized infant formulas Specialized infant formulas available at the retail level are intended for the small number of infants who cannot tolerate formulas based on intact cow's milk protein or soy protein. Most often, these infants have confirmed food allergies, carbohydrate intolerance or malabsorption syndromes. Occasionally, because of a high risk of allergy based on family history, an infant may receive a specialized formula. How Are Amino Acids Absorbed Amino acids are taken up by the cells that line the small intestine, then move out of the backside of those cells and enter the bloodstream. Meanwhile, small peptides, consisting of just a couple or a few amino acids linked together can also be brought into these cells where final digestion to amino acids can take place. Therefore, as a general rule, the absorbed form of protein will be individual amino acids. Fragments of proteins and some peptides can also be absorbed and are important in developing the immune system during infancy, and are linked to many food allergies reactions. Food allergies will be addressed in Chapter 12. Effector mechanisms of Thmediated immunity Th2-biased immune responses are believed to be important in the immune responses against helminth infections. If, however, Th2-biased immune responses are inappropriately directed against innocuous antigens, such as allergens, tissue damage and inflammation may ensue. These inappropriate Th2 responses underlie asthma, eczema, hay fever and some food allergies. Have You Ever Wondered if vegetarian eating supplies adequate nutrition for breast-feeding A vegetarian mom who consumes dairy products, and perhaps eggs, can easily get enough nutrients. For vegans, who avoid all foods of animal origin, calcium, vitamin D, iron, and vitamin B12 need special attention. See 'The Vegetarian Mom in chapter 20. if you can pass food allergens through breast milk to your baby For starters, it's highly unlikely that your baby can't tolerate breast milk allergic reactions from human milk are extremely rare. While uncommon, some babies react to allergens passed through breast milk-for example, cow milk protein or protein in peanuts. If your family has a history of food allergies, the American Academy of Pediatrics advises avoiding peanuts during the nursing period to lower your baby's peanut allergy risk. If you suspect an allergy, never make the diagnosis yourself Talk to your doctor. Then get help from a registered dietitian to help you manage any allergy and continue... Irritable Bowel Syndrome Although not completely understood, irritable bowel syndrome (IBS) seems to be more common these days than the sniffles. With symptoms ranging from excessive gas, cramping, bloating, and intermittent bouts of constipation and diarrhea, IBS (also called a spastic colon) usually has nothing to do with food allergies or intolerances. It's more likely a functional problem with the muscular movement of your intestines. In fact, it's generally diagnosed when the serious gastrointestinal ailments are ruled out. Some doctors say that people can even bring it on with anxiety or nerves. Tim A Patient Of Dr Harold Buttram I've done a lot of reading and now realize that the majority of our MD's have no nutritional background. Now that I have figured out that my son's problem is food allergies as well as allergies to environmental substances such as pollens, it really bothers me that medical doctors don't have this fundamental knowledge of nutrition on which to build. It would have been wonderful if, during those first five years, my doctor had been able to say, What do you feed your child Have you noticed a pattern Betty A Patient Of Dr Ray Wunderlich Back in 1991, I was injured on the job by some paint fumes and my whole life changed. I developed serious food allergies and sensitivities to everything in my environment. I became allergic to everything in my own home, I reacted to plastics of all kinds, and I couldn't breathe outdoor air. I was literally a captive in my own home for the first year. When I couldn't go out, all the air inside my own home had to be filtered especially for me and I had to wear charcoal face masks to breathe. Also, I began to experience depressions, mood swings, and a lot of confusion and memory loss. I would go into one room and forget why I was there. I know a lot of people have that complaint, but I had it consistently throughout the day. I would lose my memory about what I was doing. I couldn't go out in the car and drive myself to the store because I wouldn't be able to find my way. I lost the ability to read normally. Still now, two years later, I have to read things over and over and give my brain... Be careful to note allergenic ingredients For example, for a tree nut allergy Ground nuts added to a muffin batter or a breading mix may go unnoticed. Even a bottle of gourmet barbecue sauce may have nuts For a fish allergy Bottled fish sauce in a stir-fry, Worcestershire sauce, or salad dressing could be an undetected problem. Anchovies flavor some Italian foods, such as caponata. For an egg allergy Sometimes eggs are used to hold meatballs and fish croquettes together. For a soy allergy Soy flours and soy protein are used in increasingly more baked goods and other prepared foods. For a milk allergy Milk protein is in many brands of tuna. Currently many foods labeled as nondairy have casein, a milk derivative. Meat may have casein as a binder. Be careful with cooking and serving to avoid any cross-contact between the food allergen and foods prepared without the allergenic ingredient. See Allergen-Free Sharpen Your Cooking Skills on page 539. The same rule applies elsewhere for example, for a milk allergy, avoid deli meats... Have You Ever Wondered 105 if goat milk is a good substitute for cow milk for someone with lactose intolerance or with a milk allergy Goat milk has slightly less lactose 9 grams of lactose per cup, compared with 11 grams of lactose in one cup of cow milk. For a milk allergy, the protein in goat milk is similar to that of cow milk it's not a safe alternative. Clinical signssymptoms Refusal, back-arching, irritability and sleep disturbances have also been reported to be unrelated to GERD.61,62 Esophageal pain and behaviors perceived by the caregiver (usually the mother) to represent pain (e.g. crying and retching) potentially affect the response of the infant to visceral stimuli and the ability to cope with these sensations, either painful or non-painful.63 In addition, cow's milk allergy (CMA) may overlap with many symptoms of GER, and may coexist or complicate GERD in up to 40 of infants.64-66 Common Foods Associated with Intolerance Foods associated with intolerance include preserved foods, foods containing monosodium glutamate (MSG, a flavor enhancer), and specific foods such as milk, pickled herring, soy sauce, chili peppers, and nutmeg. Intolerance to lactose is a major problem for many populations. In the United States, lactose intolerance is common among those of African and Asian descent. The Native American population also has a high prevalence of lactose intolerance. For many food intolerances, including those listed above, specific chemicals or enzyme abnormalities have been identified as being associated with the intolerance. Lactose intolerance is associated with problems with the enzyme lactase. Chemicals associated with food intolerance include sulfite (in preserved foods), tyramine (in pickled herring and soy sauce), capsaicin (in chili peppers), and myristicin (in nutmeg). Keep on Drinking Sipping Gulping and Guzzlin Pregnant women with lactose intolerance should eat plenty of nondairy calcium-fortified foods, along with the special lactose-reduced products. Also, speak with your physician about calcium supplementation. (For further information on lactose intolerance, see Chapter 20.) Eating Habits and Meal Patterns The cuisine of Pacific Islander Americans varies slightly from culture to culture and is a blend of native foods and European, Japanese, American, and Asian influences. As with many cultures, food plays a central role in the culture. Pacific Islander Americans typically eat three meals a day. Breakfast is usually cereal and coffee traditional meals are eaten for lunch or dinner and fruits, fruit juices, vegetables, and nuts (e.g., peanuts and macadamia) are eaten in abundance. Milk and other dairy products are uncommon and there is a high prevalence of lactose intolerance among Pacific Islander Americans. Thus, calcium deficiency is prevalent. lactose intolerance inability to digest lactose, or milk sugar Digestion and Nutrition Amy is in a hurry and she knows the meal will be served fast and she knows the food is safe. The food may not be the tastiest in the world, or very good for her, but it will get her through lunch. Amy has eaten in this kind of place hundreds of times before. She orders a burger, fries, and a chocolate shake. She knows the burger and fries have lots of fat and salt that she does not need. She also knows the shake is risky for her. She has a form of lactose intolerance that sometimes results in abdominal cramping and diarrhea after ingesting milk products. But she is in a hurry, and at least she knows what she gets here besides, she has been thinking about the chocolate shake all morning. As you read through the chapters, you will follow Amy's lunch. You will read about what is really in her lunch, how it is digested, or broken down, and how it is absorbed into the body. The hamburger and fries she eats contain a lot of fat and salt, and the milkshake will most... Carbohydrate Loading Without Pasta Celiac disease can be difficult to diagnose because the symptoms vary from person to person. Some people experience diarrhea others complain about constipation and bloating. Your best bet is to talk with your doctor if you are having intestinal problems or have other niggling health concerns including unexplained fatigue, infertility, and lactose intolerance. Diagnosis of Carbohydrate Intolerance Carbohydrates that have not been digested or absorbed reach the colon and become fermented by the resident bacteria. Hydrogen gas is produced and is excreted in the breath. Measuring breath hydrogen thus provides an estimate of whether malabsorption of a sugar or carbohydrate occurs (see also Chapter 57). It was first used to detect lactose intolerance and has since been used in numerous studies on carbohydrate intolerance ( 60). It has a number of weaknesses for example, it gives no indication of the amount of carbohydrate absorbed before the sugar reached the colon, and the hydrogen in the breath is only a fraction of that formed. Enteric infections in HIVinfected children Intestinal microsporidiosis is increasingly being reported in patients with HIV.83,108 These intracellular protozoa are able to infect most animal species and, in humans, five genera (Enterocytozoon, Encephalitozoon, Septata, Pleistophora and Nosema) are associated with pulmonary, ocular, muscular, renal, intestinal and hepatic clinical disease. In Thailand, Enterocytozoon bieneusi was diagnosed in 25 and 15 of HIV-infected and uninfected children presenting with diarrhea, respectively.81 In Uganda, however, it was found in 17 of children of unknown HIV status attending hospital out-patient clinics for conditions other than diarrhea.82 In contrast, microsporidiosis in HIV-infected adults produces chronic watery diarrhea and wasting, suggesting that responses in children may be quite different.82,109 Villous atrophy and reduced brush-border enzyme activity may cause lactose intolerance.110 Graftversushost disease Dermatitis, enteritis and hepatic dysfunction. Upper non-specific gastrointestinal symptoms, such as nausea, vomiting, bloating and food intolerance, occur in a large proportion of patients, even in the absence of lower gastrointestinal symptoms.61 These symptoms seem to be more frequent than those arising from lower involvement and are thought to represent an early manifestation of GVHD. Endoscopic findings vary considerably, ranging from normal-appearing mucosa to exensive mucosal sloughing. Histological findings are diagnostic, including gastric epithelial cell apoptosis and a marked lymphocytic infiltrate in the lamina propria. Upper gastrointestinal GVHD appears to be highly responsive to immunosuppressive therapy. Recognizing Other Body Reactions to Food Food intolerance is a term used to describe reactions that are common, nat- r ural, and definitely not allergic, which means that these reactions do not 2 I ) involve production of antibodies by the immune system. Some common food * A metabolic food reaction This response is an inability to digest certain foods, such as fat or lactose (the naturally occurring sugar in milk). Metabolic food reactions can produce gas, diarrhea, or other signs of gastric revolt and are an inherited trait. Benefits of breastfeeding to infants in Canada For infants with a family history of atopy, maternal avoidance of specific foods (e.g. milk and dairy products, eggs, peanuts) during pregnancy and lactation has not been proven to be more effective in reducing the incidence and severity of atopy throughout the first year of life than exclusive breastfeeding without maternal food restriction (Falth-Magnusson, 1994 Zeiger et al., 1989). Risk of reduction in third trimester maternal weight gain and lower infant birth weight in the women avoiding potentially allergenic food during pregnancy illustrate the need for close nutritional monitoring. Until the efficacy of a restricted diet during pregnancy and lactation is known, routine restriction of diets of mothers of infants at risk for allergy is not recommended. Nutritional Assessment The initial assessment takes into account the diet history of the woman as well as any symptoms or problems that might hinder adequate intake. Typical dietary, appetite, gastrointestinal symptoms (i.e., nausea, vomiting, diarrhea, and constipation), difficulty with chewing and swallowing, food allergies, ethnic and cultural food practices, and household food security should be considered and included in the assessment. Furthermore, all medications and supplements as well as complementary therapies should be investigated in order to determine possible drug-nutrient interactions. Eosinophilic gastritis Eosinophilic gastritis is a component of eosinophilic gastroenteropathy, a rare disease characterized by prominent eosinophilic infiltration of the gastrointestinal tract. The cause is unknown and the mechanisms responsible for gastrointestinal infiltration by eosinophils remain poorly understood. Recently, it has been shown that the production of eotaxin, a protein with 73 amino acid residues and a member of the chekines family, at the site of inflammation promotes recruitment and aggregation of eosinophils in the tissue by up-regulating integrins and enhancing eosinophilic adhesion to endothelial cells. Finally, it may contribute to tissue damage by stimulating the release of highly cytotoxic granular proteins.53 It has been suggested that food allergy might be a triggering factor in childhood. Associations between eosinophilic gastritis and parasitic infection of the stomach have been described. Nutritional Requirements Protein is a vital dietary component for preschoolers and toddlers, as it is needed for optimal growth. Enough protein should be consumed every day to allow for proper development. Protein deficiencies are rare in the United States, since most U.S. children consume plenty of protein each day. When protein malnutrition does occur, it is usually seen in those from low-income homes, those who follow a strict vegan diet excluding all animal sources, and those with multiple food allergies. Alison A Patient Of Doctor Buttram Buttram diagnosed my daughter as having food allergies to corn, potatoes, chicken, egg yolks, rice, and chocolate. They put her on these sublingual drops and now I have my normal, happy daughter back again. It was just a dramatic change. She had become extremely difficult to live with. She would just scream at me about the most ridiculous things. Nothing was ever right. If she got out of bed--Why didn't I wake her up --Why didn't I let her sleep --And she would shriek at the top of her lungs. Some days were worse than others. Now I know that on the days she had a combination of foods or a lot of the foods she was allergic to that she was at her worst. The way that I figured out it was food again was because every once in awhile we would have a great day or two and every once in awhile her diet just happened to not include these things. Then she would be fine. But the next day she'd be right back again with the behavior--totally out of control for long periods of time. When my... Human studies on the effects of food and food components Alleviation of lactose intolerance symptoms. The majority of the world's population have low levels of 3-galactosidase in their small-bowel mucosa. Most lactase-deficient people are symptom-free if they consume only limited amounts of milk, except those subjects who are severely lactose intolerant. A beneficial effect of probiotics on lactose digestion has been demonstrated (Sanders, 1993). In particular, in studies comparing yoghurt and milk consumption it was shown that yoghurt consumption enhances lactose digestion in lactase-deficient subjects (Kolars et al. 1984 Marteau et al. 1990) and slows orocaecal transit. Alleviation of symptoms of lactose intolerance Immune enhancement The basic mechanisms of immune response to dietary antigen Show a recognizable gastrointestinal tract.118 There is much current interest on the links between innate and adaptive immune responses, in particular pattern receptor molecules such as toll-like receptors and nod proteins that induce an immune response within innate cells, such as dendritic cells, that polarize subsequent T-cell responses.119,120 Evidence that oral tolerance cannot be established normally in germ-free mice suggests that the normal flora plays an important role in the generation of tolorogenic lymphocytes and the prevention of food allergies.121,122 The potential role for probiotics in prevention of food allergies in susceptible infants is thus likely to be based on the role of luminal bacteria in inducing a tolerant lymphocyte response.8,9 Transgenic mice whose only T cells responded to ovalbumin were in fact entirely tolerant of ovalbumin feeds, unless innate immune responses to the flora were blocked using cyclo-oxygenase-2 antagonists, when food-sensitive... Digestion and Absorption Entire proteins are sometimes absorbed, too, albeit in very small amounts. Since their sequences do not correspond to any of the bodies' own proteins, they are recognized as foreign by immune-competent cells. Physiologically, the purpose of this process may be to stimulate intestinal IgA and IgG secretion, thereby maintaining an important defense mechanism. There is also discussion, however, whether increased intestinal permeability (e. g., leaky gut syndrome in neonates) might be responsible for food allergies and autoimmune diseases. Patterns of food allergic responses Quickonset symptoms The true incidence of anaphylactic death due to food allergy is unknown. A recent UK report suggested a low incidence of 0.006 deaths per 100 000 children per year,27 but this is thought to be a significant underestimate, as many cases were unlikely to be identified from the study of death certificates and clinical reporting alone.25 licular erythema (red halo sign) and an easily traumatized mucosa. Histological changes include mononuclear cell infiltration, mucosal eosinophilia with evidence of degranulation and the presence of lymphoid follicles in the majority of colonic biopsies. If the ileum is visualized, lymphoid hyperplasia is usually seen. Recent data suggest a concordance between the endoscopic finding of ileocolonic lymphoid hyperplasia and food allergies (Figure 22.1), not restricted to those infants with allergic enterocolitis alone,29 which may be associated with an increase in mucosal y T-cell infiltration.30 See also Chapter 30. Figure 22.1 Lymphoid hyperplasia is an... Carbohydrate Intolerance Adult mammals and most human groups after weaning keep only a fraction of the intestinal lactase activity of neonates (who need it to digest the lactose of breast milk). The persistence of lactase activity in Europeans has been regarded as the exception to the rule, since most human groups are hypolactasic and lactose malabsorbers (56). However, small amounts of dietary lactose, up to 250 mL of milk, can be tolerated by most adult lactose maldigesters. The decrease in lactase in adults is a programed event, and feeding high-lactose diets does not prevent the decrease. The mechanisms of the decline in activity have been studied in rats. As the animal matures, more and more mRNA message for lactase is needed to maintain the decreasing lactase activity in the enterocytes, Potential subtypes of cyclic vomiting syndrome and common associations There are several other clinical patterns that can be identified. Again, it is unclear whether they simply represent various inciting stimuli that initiate the same pathophysiological cascade, or whether they represent distinct effector pathways. We hope that delineation of clinical patterns into subgroups may ultimately point us towards potential treatment approaches. For instance, some appear to have episodes that occur after periods of fasting, often induced by illness. They appear to respond rapidly to intravenous glucose and are suspected of being heterozygote carriers of disorders of fatty acid oxidation. Others have a stable periodicity (e.g. 60 days) to their episodes independent of stress or infectious triggers. Stable periodicity has been observed in some postmenarchal girls who have episodes at the onset of their menses and often respond to birth control pills with a low estrogen dose.2 Some respond to pro-kinetic agents, but because of the lack of motility studies, it is... Post Operative Anastomotic Leak Patients in this phase are dealing with many different changes, both physiological and psychological. The small gastric pouch only allows very small portion sizes, and they feel full and satisfied. They are not hungry, and often forget to eat. Attempts at overeating result in vomiting, and they quickly learn to control portion sizes and food reactions. The patient in this phase is dealing with significant changes in comorbidities, physiological feedback, and psychological changes associated with surgery. Nutrient needs of the pregnant adolescent Important assessment data that need to be collected and evaluated to comprehensively develop educational approaches for pregnant adolescents can be categorized as follows (1) determining the quality, quantity, and rate of weight gain in pregnancy (2) evaluating current dietary intake to determine the adequacy of nutrient and energy intake during pregnancy and (3) assessing dietary issues that may affect intake, e.g., food allergies or vegetarianism 13 . Data derived from these assessments can provide a focus for discussions with all adolescents throughout pregnancy. Adolescents, especially those younger than 15 years of age, are at high risk for inappropriate maternal weight gain, anemia, and more serious complications such as lung and renal disease. Maternal weight gain is reportedly more influential than age of mother on fetal birth weight 11, 14 . Given that fetal birth weight < 3,000 g is related to increased infant morbidity and mortality, optimizing maternal weight gain should... Digestion and Absorption of Protein To a limited but important extent, some proteins and large peptides enter intact directly from the gut into the basolateral blood. Absorption of intact proteins or large portions of proteins is a tenable physiologic explanation for numerous diseases involving food allergies and idiosyncrasies. The gut is generally viewed as an impermeable barrier that nutrients cross by active transport or where a break in the barrier occurs through cell injury. Small amounts of some proteins may pass this barrier by several possible mechanisms, such as through leaks between epithelial cell junctions or possibly by transport through uptake into vesicles from the lumen to the submucosal side of the epithelial cells (142). Again, the amount of protein entering intact is small, but it may be important in situations of immune response to the proteins or in delivery of some peptide drugs. Mercury The Silent Killer In the 1940s children began appearing in pediatricians' offices with flushed faces, pink hands that constantly shed skin, and signs of various neurological illnesses. Because of the light pink coloration of their faces and hands the condition was named pink disease. In 1950 fifty-seven children died of the mysterious disorder. Doctors and scientists were baffled as to its cause and suggested everything from an infectious disease to food allergies. Some noted that many of its features resembled mercury poisoning, but they were ignored until it finally came to light that a teething powder used by the children contained high concentrations of mercury when the teething powder was withdrawn from the market pink disease disappeared. Itching for a Cause If you have symptoms, a doctor can help you find the cause with a medical diagnosis. A board-certified allergist (certified by the American Academy of Allergy, Asthma, and Immunology) is best equipped to diagnose food allergies. Never try to self-diagnose. Someone with a food allergy should be under a doctor's care. True food allergies can be measured and evaluated clinically with no need for hunches. In that way unrelated medical conditions are eliminated. Typically the diagnosis includes a medical history, a physical exam, and possibly a food diary, elimination diet, and laboratory tests. As an initial screening your doctor may use a skin test an allergist will confirm a food allergy with more definitive tests. Check Pass the Test later in this chapter. Keeping track of how your body reacts to a specific food one time after another may help you detect a food allergy or intolerance on your own. But be careful about self-diagnosis. The cause may be a more serious medical problem.... Definitions The term adverse reaction is used to describe health problems linked to food. Food allergy and food intolerance are two types of adverse food reactions (food-borne illnesses caused by bacterial, viral, or other forms of contamination are also adverse reactions). A food allergy is said to exist when the health problem is linked to a malfunction of the immune system. It is believed that this malfunctioning occurs when the body identifies a food protein (allergen) as a harmful substance. Food intolerance occurs when the underlying problem causing the adverse reaction is not related to a malfunction of the immune system. One example of a food intolerance is lactose intolerance, a condition affecting people who cannot digest milk due to a deficiency of the enzyme lactase, which breaks down milk sugar (lactose). Food allergies can be triggered by almost any food. The most common food allergies are caused by wheat, nuts, fish, eggs, milk, and soy. Wheat, milk, and soy are also common causes... Previous page 131 The most common allergenic foods on a worldwide basis are cows' milk, eggs, peanuts, soybeans, tree nuts, wheat, crustaceans and fish (15). Allergies to cows' milk, eggs, soybeans and wheat are much more common among infants than among adults because these food allergies are frequently outgrown. Other countries may experience different patterns of food allergy. In Japan, for example, peanut allergy is rare, while soybean and rice allergies are much more common than in North America. This is probably the result of the popularity of the food in the various countries. The above list of eight foods or food groups, sometimes referred to as the Big Eight, probably accounts for 90 of all food allergies. It is possible to develop an allergy to any food that contains protein over 160 other foods have been reported on at least rare occasions to cause food allergy (16). The most common allergenic foods are foods with high protein contents that are frequently consumed. However, beef, pork and... Previous page 140 Headache As an Expression of Food Allergy The proposed relationship between food allergy and headache is controversial. Some researchers have asserted that migraine itself may be an expression of food allergy (30, 31). The majority of researchers investigating this possible link, however, have dismissed the possibility that the vast majority of food-induced migraines are caused by food allergies (7, 32). One common link between allergy and food-induced migraine is that vasoactive amines (most notably histamine) are released during an allergy attack, and increased levels of plasma histamine have been identified during migraine episodes (33), as well as in migraine patients when they ingest implicated trigger foods (34). Studies that have examined RAST or skin prick tests of allergies in comparison to identified food triggers of migraine, however, have rarely identified any link between positive allergy findings and food-induced headache. Schuller et al. (35) have reviewed the research... Previous page 128 Food Allergy, Intolerance and Behavioral Reactions Steve L. Taylor and Susan L. Hefle Lucretius once said, 'One man's food is another man's poison.' Food allergies and intolerances, also known collectively as food sensitivities, are food-related illnesses that affect some consumers but not others. While Lucretius was not referring to food allergies and intolerances, he could have been. Several distinct types of illnesses are included among the food sensitivities (1, 2). True food allergies are those illnesses that involve an abnormal or heightened response of the body's immune system to specific food components. Several different types of true food allergies exist which have different immunological mechanisms. Food intolerances, on the other hand, do not involve immunological mechanisms. Again, several different types of food intolerances exist. The distinction between the mechanisms involved in true food allergies and food intolerances has some practical importance. Individuals with... Absorption Nutrient absorption is efficient because the GI tract is folded with several surfaces for absorption and these surfaces are lined with villi (hairlike projections) and microvilli cells. As one nutrition textbook puts it, each person has a surface area equivalent to the surface of a tennis court packed into his or her gut (Insel et al., p. 81). Efficient absorption can be compromised due to lactose intolerance. Lactose intolerance is not uncommon in the world, affecting about 25 percent of the U.S. population and 75 percent of the worldwide population. It is usually due to the lack or absence of the enzyme lactase, which breaks down milk sugar. Lactose intolerance is not a food allergy. Food allergies are serious, even life threatening, but most people with lactose intolerance can digest small amounts of milk, especially in yogurt and cheese. Conclusions Convincing evidence exists for an important role of breast-feeding in the defence against mucosal infections. Its role in oral tolerance and protection against food allergy has been much more difficult to establish conclusively. This is not surprising in view of the complex and poorly understood interface between these two enigmatic biological phenomena, with multiple potential interactions influenced by the numerous bioactive components of breast milk (Fig. 14.9). For ethical reasons, it will not be possible to assign infants to breast-or formula-feeding for long-term follow-up studies. Therefore, perhaps we shall just have to take it on trust that exclusive breast-feeding for several months, followed by mixed feeding, is the natural way to begin life for all mammals, including humans. Previous page 130 No symptoms occur during the sensitization process. However, upon a second exposure of the sensitized individual to the same allergen, the allergen cross-links IgE molecules on the surface of the mast cell or basophil membrane, stimulating the cells to degranulate and release the mediators mentioned above. These mediators circulate throughout the body and interact with receptors in various tissues, leading to the development of a wide range of possible symptoms. In IgE-mediated allergies, the interaction of very small amounts of the allergen with the membrane-bound IgE results in the release of massive quantities of histamine and the other mediators. Hence, consumers with IgE-mediated food allergies have a very low tolerance for the offending food. Individuals with IgE-mediated food allergies can tolerate very little of the offending food in their diet. Recent studies have shown that the tolerance dose for peanut among peanut-allergic individuals ranges from 2 mg to > 50 mg for... Previous page 129 True Food Allergies As noted above, true food allergies involve abnormal immunological responses of the body to substances in foods. The allergens are typically naturally occurring proteins that are present in certain foods. However, the true food allergies can be divided into two categories antibody-mediated or cell-mediated reactions. The antibody-mediated food allergies are usually mediated by allergen-specific immunoglobulin E (IgE) antibodies, while cell-mediated food allergies are mediated by sensitized lymphocytes (2). IgE-Mediated Food Allergies IgE-mediated food allergies are also referred to as immediate hypersensitivity reactions. Symptoms develop within a few minutes to a few hours after the inadvertent ingestion of the offending food. In IgE-mediated food allergies (Fig. 14.1), susceptible individuals will form allergen-specific IgE antibodies upon exposure to an allergen (8). The IgE attaches itself to mast cells in various tissues of the body and basophils in the blood.... Previous page 134 The food industry including the confectionery industry bears considerable responsibility for the prevention of allergic reactions, especially IgE-mediated, true food allergies. Since individuals with IgE-mediated food allergies must specifically avoid their offending foods and can tolerate very little of the offending food, the food industry must properly and completely declare the presence of allergenic foods on the ingredient labels of their packages. Allergic consumers are avid label readers. They also frequently call food companies seeking additional information and must be given accurate answers. If food products inadvertently become contaminated with even small amounts of an allergenic food which is unlabeled, the consequences can be serious indeed. Individuals with IgE-mediated food allergies can react adversely to the ingestion of traces of the offending food, sometimes with devastating consequences. If larger amounts of the offending food are present, severe reactions can... Diet Allergies Food sensitivity can develop at any age but is particularly common in infants and young children. About 7-10 of children exhibit food allergies during their growing years.1 Colic in babies may be caused by sensitivity to a food -a common allergen is the protein in cow's milk. Adults can also develop sensitivity reactions, particularly when the immune system is knocked off-balance by stress, illness, food additives, and poor nutrition. Food allergies are often difficult to identify. Although many diagnostic tests have been tried, none is entirely satisfactory. Elimination of suspected foods from the diet is the most direct and reliable method if one of the eliminated foods was causing the reaction, improvement will occur.1,4,14 Foods must be eliminated for at least 5 days (and often for 2-4 weeks) to allow time for their adverse effects to completely disappear. If improvement occurs, the eliminated foods should be rein- Because a food once caused a sensitivity reaction doesn't mean it... Previous page 137 FAO (1995) Report of the FAO Technical Consultation on Food Allergies. Food and Agriculture Organization, Rome. Hefle, S.L., Nordlee, J.A. and Taylor, S.L. (1996) Allergenic foods. Crit. Rev. Food Sci. Nutr. Suarez, F.L. and Savaiano, D.A. (1997) Diet, genetics, and lactose intolerance. Food Technol. Previous page 135 Immunoassays currently in various stages of development will allow the detection of residues of specific allergenic foods in other products (38). There are presently such immunoassays available for the detection of peanut, milk, egg and almond residues in other foods. The sensitivity of these immunoassays approaches 1 p.p.m. Unfortunately, satisfactory analytical methods for the detection of residues of other commonly allergenic foods do not yet exist. The best approach to the assessment of the adequacy of cleaning procedures is to test samples of the first product made on the shared equipment after flushing or clean-up following the processing of products containing major allergenic foods such as peanuts. With respect to ingredients, any ingredient derived from an allergenic food that contains protein could elicit allergic responses. Refined oils do not contain protein residues and are probably safe (3941), although some countries have chosen to require source labeling of oils. Previous page 139 Assuming that at least some individuals experience food-triggered headaches, two main theories have been presented to account for this effect. The first is that vasoactive amines in food affect blood vessels in the brain, causing the vasodilatation associated with migraine pain. According to the vascular theory of migraine, a migraine episode is associated with changes in the vascular system, with a period of vasoconstriction (a decrease in blood flow to the brain, often associated with an 'aura'), followed by a reactive vasodilatation which is associated with the sensation of throbbing pain. Vasoactive amines in foods such as chocolate are thought to trigger vascular reactions in those who are prone to migraine or sensitive to the effects of that particular amine. The second, more controversial hypothesis is that these patients suffer from food allergies and that migraine pain is an allergic reaction. Dr Robert Atkins The second mechanism is food allergies, which works a little differently. First you eat the offending food--which is often a grain, or milk, or sometimes some of the protein foods. Usually, the foods you are allergic to are whatever you eat most often, and since in our culture so many people eat bread with every meal, you have to suspect wheat. A lot of people drink milk with every meal, so dairy is a prime allergen. After eating foods you are allergic to over a long period of time, you may develop a leaky gut syndrome, and then you will develop the inability to handle the protein complexes that are characteristic of that food. So you get a reaction after you eat it. With the blood sugar instability, on the other hand, you get your reaction before a meal, if you haven't eaten, or if you have eaten sweets and then you haven't eaten anything else, which is the classical way to get it. The third mechanism of this triumvirate is yeast, specifically candida albicans. The yeast itself is... Dieting So-called fad diets are diets that come and go in the marketplace and are typically deficient in various ways. For example, they may lack variety (e.g., the Grapefruit Diet, the Cabbage Soup Diet), be too low in calories and protein (the Rice Diet), and or simply too bizarre (the Rotation Diet for food allergies). People should be especially wary of any breakthrough quick-fix diets. If a diet sounds too good to be true, it probably is. Methodology The definition of biomarkers is still incomplete. Several methodologies have been developed for IgA response measurements. Sampling needs blood collection or intestinal biopsies or stool and saliva collection. Problems in faeces and saliva handling and daily variations in expression of IgA activities have not been solved. In the case of oral tolerance, the biomarkers available in human subjects are defined as the absence of proliferation of cultured blood cells with antigen or down-regulation of inflammatory cytokines involved with food allergies (Benlounes et al. 1996 Siitas et al. 1996a,b). Other methodologies must be developed according to further knowledge about oral tolerance mechanisms (Weiner et al. 1994). Super Shake Recipe As mentioned above, although most of your daily protein should come from whole food protein sources, getting all of your protein in this way isn't always possible or practical. That's when the protein supplements should come into play. Yet milk protein supplements aren't the only type to choose from. Other protein supplements on the market are made from egg protein, soy protein, rice protein, and other foods. Although milk protein supplements are the most popular, if you have a milk allergy or milk proteins supplements make your stomach uncomfortable, try another type of protein supplement. Calcium Some persons with celiac disease, especially those who are newly diagnosed, may have a secondary form of lactose intolerance. Lactose is a type of sugar found in milk. To be digested, it must be broken down in the small intestine by the enzyme lactase. Persons newly diagnosed with celiac disease may have low levels of lactase as a result of damage to the lining of the small intestine. As the small intestine heals in response to a gluten-free diet, the lactose intolerance will naturally resolve. Until it does, a lactose-reduced or lactose-free diet is generally recommended. Because individuals with lactose intolerance may avoid milk products, and because milk products are a major source of calcium in the American diet, persons with celiac disease who also are lactose intolerant may not consume enough calcium. Previous page 133 Food Intolerances Several types of food intolerances exist. The major categories include anaphylactoid reactions, metabolic food disorders and idiosyncratic reactions (2). The anaphylactoid reactions are not discussed further here because there is no conclusive proof that such reactions occur related to foods. Metabolic food disorders occur in individuals who are unable to normally metabolize a food component. Lactose intolerance is the best example, and is an example that has relevance to chocolate manufacturing (see below). Idiosyncratic reactions are those illnesses that occur through unknown mechanisms. By definition, relatively little is known about idiosyncratic reactions. In many cases, the cause-and-effect relationship with specific foods or food components has not been well established. The role of sugar in hyperkinetic and other abnormal behaviors in children is discussed briefly below as an example of an idiosyncratic reaction. Individuals with these various forms of... El Gluten Free Diet Celiac disease is an inherited autoimmune disease that usually affects several organs in the body before it is diagnosed and treated. When a person with celiac disease consumes any food, beverage, or medication containing wheat, barley, rye, and possibly oats, his or her immune system is triggered and responds by damaging the lining of the intestinal tract. As a result, symptoms include recurrent abdominal pain, bloating, diarrhea, weight loss, lactose intolerance, and malnutrition, often accompanied by nonintestinal symptoms such as anemia and fatigue. Some people have no symptoms whatsoever. Osteomalacia Lactose intolerance inability to digest lactose, or milk sugar Osteomalacia is a disease in which insufficient mineralization leads to a softening of the bones. Usually, this is caused by a deficiency of vitamin D, which reduces bone formation by altering calcium and phosphorus metabolism. Osteomalacia can occur because of reduced exposure to sunlight (which, after touching the skin, causes the body to make vitamin D), insufficient intake of vitamin D-enriched foods (like vitamin D-fortified milk), or improper digestion and absorption of food with vitamin D (as in bowel disorders such as lactose intolerance or celiac disease). East Africa Two herding tribes, the Maasai and Fulbe, have a notably different eating pattern. They do not eat very much meat, except for special occasions. Instead, they subsist on fresh and soured milk and butter as their staples. This is unusual because very few Africans consume milk or dairy products, primarily due to lactose intolerance. Clinical Diagnosis The lactose tolerance test involves an individual drinking a liquid that contains lactose. The individual must fast before this test, in which several blood samples are taken over a two-hour period to measure the blood glucose level, which indicates how well the body is able to digest lactose. If lactose is incompletely absorbed, then the blood glucose level will not rise, confirming a diagnosis of lactose intolerance. Malabsorption Lactose intolerance is one of type of malabsorption syndrome, a collection of conditions that cause problems in getting nutrients to the body. There are four of these types of conditions. A person can have problems absorbing only one type of nutrient, such as lactose. A person can have problems producing or delivering gastric juices into the stomach, or pancreatic digestive enzymes, or bile from the gallbladder. A person may have a congenital or developmental problem in the small intestine such that once nutrients are absorbed through the intestinal wall, the water-soluble material must be transported to the liver for processing (see Chapter 6). If there is something wrong with this part of the circulatory system, nutrients will not be Food Habits There exists great diversity in language, socioeconomic status, religion, age, education, social class, location, length of time in the United States, and country of origin among Asian Americans. Hence, caution needs to be taken not to generalize or imply that food habits are similar for all individuals of this group. For example, Chinese meals consist mainly of four food groups grains, vegetables, fruit, and meat. Because of lactose intolerance, most Chinese do not consume large amounts of dairy products, substituting soymilk and tofu as sources of protein and calcium. Some Asian food, such as Thai food, is generally spicy, hot, and high in sodium. Hot peppers are used daily. The Japanese are very concerned about the visual appeal of food and the separateness of the foods and tastes. Garlic and hot pepper, commonly used among Asian Americans, are not common ingredients in the Japanese cuisine. Korean Americans eat kimchi with each meal. Kimchi is cabbage marinated in salt water,... Carbohydrates Table sugar, the sugar that we spoon onto our cereal and add to the cookies we bake, also called sucrose, is the most familiar simple sugar. A ring-shaped molecule of sucrose actually consists of a molecule of fructose chemically linked to a molecule of another simple sugar called glucose. Sugars such as fructose and glucose are known as monosaccharides, because of their single (mono) ring structure, whereas two-ringed sugars such as sucrose are known as disaccharides. Another disaccharide, lactose, the sugar that gives milk its slightly sweet taste, consists of glucose linked to yet another simple sugar called galactose. The inability to digest lactose to its constituent sugars is the cause of lactose intolerance, a condition common to adults of Asian, Mediterranean, and African ancestry. Future trends Carroccio A, Montalto G, Cavera G et al. Lactose intolerance and self-reported milk intolerance relationship with lactose maldigestion and nutrient intake. Lactase Deficiency Study Group. J Am Coll Nutr 1998 17 631-636. Young E, Stoneham MD, Petruckevitch A et al. A population study of food intolerance. Nanda R, James R, Smith H et al. Food intolerance and the irritable bowel syndrome. Dainese R, De Galliani EA, Lazzari F et al. Discrepancies between reported food intolerance and sensitization test findings in irritable bowel syndrome patients. Am J Gastroenterol 1999 94 1892-1897. Aggett PJ, Agostoni C, Axelsson I et al. Nondigestible carbohydrates in the diets of infants and young children a commentary by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr 2003 36 329-337. Saldanha LG. Fiber in the diet of US children results of national surveys. Hillemeier C. An overview of the effects of... Pathophysiology The biopsychosocial model, proposed as an alternative to the traditional biomedical model, conceptualizes the general state of health as resulting from the integration of medical and psychosocial factors. To understand this model, one should differentiate between disease, which is the abnormality of the structure and or function of organs and tissues (physical component), and illness, defined as the patient's perception of health and bodily dysfunction (psychological component). In Engel's model,57 illness and disease result from interactions at the cellular, tissue, interpersonal and environmental levels resulting in a clinical outcome. The biopsycho-social model assumes that genetic influences on disease susceptibility and behavior result in a biological and psychosocial predisposition that will influence later psychosocial experiences, physiological functioning, or susceptibility to a pathological condition. This particular background is affected by physical and environmental... Treatment A detailed dietary history may identify factors that patients may feel as aggravating or provoking the symptoms. Food intolerance was perceived as a problem by 20 in an unselected UK population who responded to a questionnaire, but with controlled challenge the prevalence was slightly higher than 1 .119 Food-induced symptoms are common reports among IBS patients, with 20-65 attributing their symptoms to adverse food reac-tions.120,121 In a study of 200 IBS patients,120 the effect of an exclusion diet was evaluated, with a symptomatic improvement in almost 50 of patients, indicating that a significant proportion of IBS patients could benefit from therapeutic dietary manipulation. However, such intervention is still controversial because the observed response rate replicates the average placebo response rate in IBS trials.40 Within IBS patients the subgroup of patients with diarrhea-predominant symptoms seems to benefit the most by a trial of exclusion diet. Among those with abdominal... Previous page 136 Lemke, P.J. and Taylor, S.L. (1994) Allergic reactions and food intolerances. In Nutritional Toxicology (Ed. by Kotsonis, F.N., Mackey, M. and Hjelle, J.), pp. 11737. Raven Press, New York. Niestijl Jansen, J.J., Kardinaal, A.F.M., Huijbers, G.H., Vlieg-Boestra, B.J., Martens, B.P.M. and Ockhuizen, T. (1994) Prevalence of food allergy and intolerance in the adult Dutch population. Allergy Clin. Immunol. Young, E., Stoneham, M.D., Petruckevitch, A., Barton, J. and Rona, R. (1994) A population study of food intolerance.