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1 FOOD ALLERGY AND INTOLERANCES Food allergies or food intolerances affect nearly everyone at some point. People often have an unpleasant reaction to something they ate and wonder if they have a food allergy. One out of three people either say that they have a food allergy or that they modify the family diet because a family member is suspected of having a food allergy. But only about three percent of children have clinically proven allergic reactions to foods. In adults, the prevalence of food allergy drops to about one percent of the total population. This difference between the clinically proven prevalence of food allergy and the public perception of the problem is in part due to reactions called "food intolerances" rather than food allergies. A food allergy, or hypersensitivity, is an abnormal response to a food that is triggered by the immune system. The immune system is not responsible for the symptoms of a food intolerance, even though these symptoms can resemble those of a food allergy. It is extremely important for people who have true food allergies to identify them and prevent allergic reactions to food because these reactions can cause devastating illness and, in some cases, be fatal. How Allergic Reactions Work An allergic reaction involves two features of the human immune response. One is the production of immunoglobulin E (IgE), a type of protein called an antibody that circulates through the blood. The other is the mast cell, a specific cell that occurs in all body tissues but is especially common in areas of the body that are typical sites of allergic reactions, including the nose and throat, lungs, skin, and gastrointestinal tract. The ability of a given individual to form IgE against something as benign as food is an inherited predisposition. Generally, such people come from families in which allergies are common-not necessarily food allergies but perhaps hay fever, asthma, or hives. Someone with two allergic parents is more likely to develop food allergies than someone with one allergic parent. Before an allergic reaction can occur, a person who is predisposed to form IgE to foods first has to be exposed to the food. As this food is digested, it triggers certain cells to produce specific IgE in large amounts. The IgE is then released and attaches to the surface of mast cells. The next time the person eats that food it interacts with specific IgE on the surface of the mast cells and triggers the cells to release chemicals such as histamine. Depending upon the tissue in which they are released, these chemicals will cause a person to have various symptoms of food allergy. If the mast cells release chemicals in the ears, nose, and throat, a person may feel an itching in the mouth and may have trouble breathing or swallowing. If the affected mast cells are in the gastrointestinal tract, the person may have abdominal pain or diarrhea. The chemicals released by skin mast cells, in contrast, can prompt hives. Food allergens (the food fragments responsible for an allergic reaction) are proteins within the food that usually are not broken down by the heat of cooking or by stomach acids or enzymes that digest food. As a result, they survive to cross the gastrointestinal lining, enter the bloodstream, and go to target organs, causing allergic reactions throughout the body. The complex process of digestion affects the timing and the location of a reaction. If people are allergic to a particular food, for example, they may first experience itching in the mouth as they start to eat the food. After the food is digested in the stomach, abdominal symptoms such as vomiting, diarrhea, or pain may start. When the food allergens enter and travel through the bloodstream, they can cause a drop in blood pressure. As the allergens reach the skin, they can induce hives or eczema, or when they reach the lungs, they may cause asthma. All of this takes place within a few minutes to an hour. Common Food Allergies In adults, the most common foods to cause allergic reactions include: shellfish such as shrimp, crayfish, lobster, and crab; peanuts, a legume that is one of the chief foods to cause severe anaphylaxis, a sudden drop in blood pressure that can be fatal if not treated quickly; tree nuts such as walnuts; fish; and eggs. In children, the pattern is somewhat different. The most common food allergens that cause problems in children are eggs, milk, and peanuts. Adults usually do not lose their allergies, but children can sometimes outgrow them. Children are more likely to outgrow allergies to milk or soy than allergies to peanuts, fish, or shrimp. The foods that adults or children react to are those foods they eat often. In Japan, for example, rice allergy is more frequent. In Scandinavia, codfish allergy is more common. Cross Reactivity If someone has a life-threatening reaction to a certain food, the doctor will counsel the patient to avoid similar foods that might trigger this reaction. For example, if someone has a history of allergy to shrimp, testing will usually show that the person is not only allergic to shrimp but also to crab, lobster, and crayfish as well. This is called cross-reactivity. Another interesting example of cross-reactivity occurs in people who are highly sensitive to ragweed. During ragweed pollination season, these people sometimes find that when they try to eat melons, particularly cantaloupe, they have itching in their mouth and they simply cannot eat the melon. Similarly, people who have severe birch pollen allergy also may react to the peel of apples. This is called the "oral allergy syndrome." Differential Diagnoses A differential diagnosis means distinguishing food allergy from food intolerance or other illnesses. If a patient goes to the doctor's office and says, "I think I have a food allergy," the doctor has to consider the list of other possibilities that may lead to symptoms that could be confused with food allergy. One possibility is the contamination of foods with microorganisms, such as bacteria, and their products, such as toxins. Contaminated meat sometimes mimics a food reaction when it is really a type of food poisoning. There are also natural substances, such as histamine, that can occur in foods and stimulate a reaction similar to an allergic reaction. For example, histamine can reach high levels in cheese, some wines, and in certain kinds of fish, particularly tuna and mackerel. In fish, histamine is believed to stem from bacterial contamination, particularly in fish that hasn't been refrigerated properly. If someone eats one of these foods with a high level of histamine, that person may have a reaction that strongly resembles an allergic reaction to food. This reaction is called histamine toxicity. Another cause of food intolerance that is often confused with a food allergy is lactase deficiency. This most common food intolerance affects at least one out of ten people. Lactase is an enzyme that is in the lining of the gut. This enzyme degrades lactose, which is in milk. If a person does not have enough lactase, the body cannot digest the lactose in most milk products. Instead, the lactose is used by bacteria, gas is formed, and the person experiences bloating, abdominal pain, and sometimes diarrhea. There are a couple of diagnostic tests in which the patient ingests a specific amount of lactose and then the doctor measures the body's response by analyzing a blood sample. Another type of food intolerance is an adverse reaction to certain products that are added to food to enhance taste, provide color, or protect against the growth of microorganisms. Compounds that are most frequently tied to adverse reactions that can be confused with food allergy are yellow dye number 5, monosodium glutamate, and sulfites. Yellow dye number 5 can cause hives, although rarely. Monosodium glutamate (MSG) is a flavor enhancer, and, when consumed in large amounts, can cause flushing, sensations of warmth, headache, facial pressure, chest pain, or feelings of detachment in some people. These transient reactions occur rapidly after eating large amounts of food to which MSG has been added. Sulfites can occur naturally in foods or are added to enhance crispness or prevent mold growth. Sulfites in high concentrations sometimes pose problems for people with severe asthma. Sulfites can give off a gas called sulfur dioxide, which the asthmatic inhales while eating the sulfited food. This irritates the lungs and can send an asthmatic into severe bronchospasm, a constriction of the lungs. Such reactions led the U.S. Food and Drug Administration (FDA) to ban sulfites as spray-on preservatives in fresh fruits and vegetables. But they are still used in some foods and are made naturally during the fermentation of wine, for example. There are several other diseases that share symptoms with food allergies including ulcers and cancers of the gastrointestinal tract. These disorders can be associated with vomiting, diarrhea, or cramping abdominal pain exacerbated by eating. Gluten intolerance is associated with the disease called gluten-sensitive enteropathy or celiac disease. It is caused by an abnormal immune response to gluten, which is a component of wheat and some other grains. Some people may have a food intolerance that has a psychological trigger. In selected cases, a careful psychiatric evaluation may identify an unpleasant event in that person's life, often during childhood, tied to eating a particular food. The eating of that food years later, even as an adult, is associated with a rush of unpleasant sensations that can resemble an allergic reaction to food.
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