Update on Food Allergy Food Allergen Bureau Vincent St Aubyn Crump FRCP(UK), FRACP Auckland Allergy Clinic October 14, 2008 ALLERGY Sensitization Food protein B cell T lymphocyte IgE Antibody Food Anaphylaxis Elicitation/ Reactivity Mast cell/ Basophil Skin- itchiness, flushing, hives, swelling, eczema GI- nausea, vomiting, abdominal pain, diarrhea Respiratory- tightness, runny nose, wheezing, throat closing/swelling Vascular- dizziness, low blood pressure, heart irregularities, shock Subjective 1
UK New Zealand Australia Republic of Ireland Canada Peru Costa Rica Brazil USA Paraguay Uruguay Panama Kuwait South Africa Malta Finland Lebanon Kenya Germany France Japan Thailand Sweden Hong Kong Philippines Belgium Austria Iran Argentina Estonia Nigeria Spain Chile Singapore Malaysia Portugal Uzbekistan Oman Italy Pakistan Latvia Poland Algeria South Korea Morocco Mexico Ethiopia India Taiwan Russia China Greece Georgia Romania Albania Indonesia 0 5 10 15 20 25 30 35 40 Prevalence of asthma symptoms (%) 12-month prevalence of asthma symptoms in ISAAC ISAAC Steering Committee Lancet 1998 Admissions for Anaphylaxis in NHS Hospitals in the UK 2
Increasing Prevalence of Peanut Allergy in the UK Isle of Wight cohort study 3.50% 3.00% 2.50% 2.00% 1.50% peanut sensitization Peanut Allergy 1.00% 0.50% 0.00% 1989 '94-'95 3
Atopic Iceberg Clinical Allergy Eczema Asthma Hay Fever Food Allergy Sensitized Atopic or Latent Allergy (Potential to develop the disease) Adverse reaction to a Food (Any abnormal reaction from food ingestion) Toxic Scombroid fish poisoning Bacterial food poisoning poisoning Non-toxic Psychologic intolerance Pavlovian conditioning ofood aversion Food Allergy (Immune) IgE-Mediated (Immediate) Anaphylaxis Urticaria Asthma Atopic Derm Oral Allergy Mixed (IgE & non-ige) [Intermediate] Esinophilic oesophagitis Non- IgE Coeliac Food Intolerance (non-immune) Metabolic Lactose Intolerance Pharmacologic Caffeine anxiety Histamine sinsitivity Salicylate sensitivity Idiosyncratic Sulfite sensitivity 4
The adverse reactions to foods Psychological / Emotional Psychological burden associated with genuine food allergy & intolerances Psychological (conditioned) food responses Acute urticaria (hives) - 20% in kids Eczema up to 60% Oral Allergy Syndrome -40% hay fever sufferers Coeliac Disease Asthma 5% Sulfite-induced induced Gastrointestnal Syndromes Eosinophilic Esophagitis Protein enterocolitis Lactose Intolerance Anaphylaxis 35% Fear & Phobias Death risk <? Prevalence of Food Allergy in young children Food Country Children Adult USA AUS FRA NOR CHINA DEN* USAU Milk 2.5% 2.0% 1.1% 3.2% 1.7% 0.65 0.3% Egg 1.3% 3.2% 0.6% 2.0% 3.0% 1.6% 0.2% Peanut 0.8% 1.9% 0.7% - 0.3% 0.3% 0.6% Tree nuts 0.2% 0.3% 0.7% - - - 0.5% Fish 0.1% 0.07 - - 0.3% - 0.4% Shellfish 0.1% - 1.4% - - - 2.0% Sesame - 0.4% - - - - - Overall 6% 7.77 6% - 5.2% - 3.7% * Point prevalence 5
Food Allergies causing Anaphylaxis in Canberra (60.9% of cases): Foods % Median Age Peanut / tree nuts/ seeds: 26 7 Peanut 14.4 4 Tree nut / seed 11.4 13 Peanut + Tree nut/seed 12.3 5 Egg 11.4 3 Fruit / Vegetables 11.1 30 Wheat 6.7 31 Crustaceans 6.2 34 Scaly fish 5.1 13 Cow s s milk 4.4 3 Soy 1.9 20 Meat 1.6 29 Gelatine 0.9 54 Alginate (seaweed) thickener 0.2 40 Mandatory Food Allergen/Food Intolerance Labelling ANZFA Cereals containing gluten and their products (wheat, rye, barley, oats and spelt and their hybridised strains) Crustacea (e.g. crayfish, crabs, prawns) and their products Egg and egg products Fish and fish products Milk and milk products Nuts and sesame seeds and their products Peanuts and soybeans, and their products Added sulphites in concentrations of 10mg/kg or more 6
Mandatory labelling contd. Food products containing these substances must be declared when present as: An ingredient An ingredient of a compound ingredient A food additive or component of a food additive A processing aid or component of a processing aid These allergens can be declared in the ingredient list Mandatory food allergens in EU celery cereals containing gluten (including wheat, rye, barley and oats) crustaceans (including prawns, crabs and lobsters) eggs fish lupin milk molluscs (including mussels and oysters) mustard nuts, such as almonds, hazelnuts, walnuts, Brazil nuts, cashews, pecans, pistachios and macadamia nuts peanuts sesame seeds soybeans sulphur dioxide and sulphites (preservatives used in some foods and drinks) at levels above 10mg per kg or per litre 7
The Coeliac dilemma The FSANZ standard for gluten free food Final Assessment Report, (P264) has now been passed by the Food Standards Council and the food regulations changed to state the following: Standard 1.2.8 Claims in relation to gluten content of food A claim to the effect that a food is gluten free must not be made in relation to a food unless the food contains no (a) detectable gluten; and (b) no (i) oats or their products; or (ii) cereals containing gluten that have been malted, or their productsp A claim to the effect that a food has a low gluten content must not be made in relation to a food unless the food contains no more than 20 mg gluten g per 100g of the food. The major change has been in the Low Gluten claim, which now makes a maximum level of 20mg gluten/100g of food as the sole criteria for making g a low gluten claim. The prohibition on oats and malt has also been removed for the low l gluten claim. The NZ Society of Gastroenterologists and the NZ Dietetic Association have stated that the Low Gluten Standard is generally considered the appropriate treatment standard for those with coeliac disease. 8
What is the main purpose of laws on food allergens? To prevent death? or To improve quality of life? 9
10
Facts on Peanut Allergy About 1-21 2 % in children in developed countries Commonest food causing death Peanut deaths are rare vs children road deaths In UK prevalence of sensitization up from 1.3 to 3.2% from 89 to 95 75% of reactions occur on 1 st known exposure Sensitization probably doesn t t occur in utero, As little as 100ug can cause rxn (kissing) Usually associated with other food allergies Current preventative measures not working More common in siblings (7%), Heritability=81% Only ~20% outgrown & probably recur Very high toll on Quality of life of families Should peanuts be banned in schools? 11
Arguments against banning Peanuts from Schools Technically impractical May cause undue burden on unaffected Slippery slope- ban other 7 foods? Which? May create false sense of security Not a real world situation For: Make life easier for all Peanut allergic and families Goat s s feta cheese anaphylaxis 12
Emerging Problem? 13
Kiwi fruit Allergy New Zealand started growing the fruit for export since 1906, but the first report of allergic reaction to kiwi occurred relatively late in 1981. Risk factors: Birch allergy & Latex allergy Age: It occurs at all ages, but is more common in adults than in children In one study in Spain (a birch-free area) 43 patients with kiwi allergy 21% of the patients were not allergic to pollens & 46% of patients experienced systemic (generalized / anaphylactic) reaction. They had no pollinosis Clinical Manifestations of kiwi allergy Oral Allergy Syndrome, which is itching of the inside of the mouth, tongue & pharynx, associated with itching and swelling of the lips. This is probably the commonest manifestation of kiwi allergy. 83% in a Swedish study Acute Urticaria (hives) 18% Rhinoconjunctivitis (itchy eyes & nose) 6% Difficulty swallowing, nausea, vomiting - 4% Asthma 4% Anaphylaxis 14
Severity of kiwi allergy In another Swedish study of 361 kiwi allergic patients, the severity was graded as follows: Mild Symptoms 40% Moderate 32% Severe 28% Foods associated with Kiwi allergy: strongly to Apple and Hazelnut, moderately to Carrot, Potato, and Avocado, and weakly to Wheat and Rye flour, Pineapple and Papaya, and their enzymes bromelain and papain Oral Allergy Syndrome 15
Foods that cause OAS Foods associated with birch pollen allergy Fruits: Apples*, kiwi*, apricot*, peach*,, pear, plum, prune, cherry, nectarine Vegetables Carrot, celery*,, parsnip,, potato*,, tomato, Parsley,, coriander, green pepper, fennel, dill Peanut, peas, lentils, beans*, Nuts Hazelnut*,, Walnut, Almond Seeds: Sunflower Foods associated with grass pollen allergy Orange, kiwi, watermelon, melon, tomato, potato, peanut Foods associated with Olive pollen allergy Pear, Peach, kiwi, melon, nut * Reported to cause anaphylactic reaction 16
Rosaceae: Prunoideae subfamily Peach Almond Cherry Pomoideae subfamily Apple Pear Rosoideae subfamily Strawberry Blackberry Fruit Families About 50% of patients allergic to 1 fruit from the Rosaceae family will have cross-reactivity reactivity to another member of the family 17
The Carrot Family or Parsley family (Umbelliferae or Apiaceae) Parsley Coriander Fennel Cumin Anise Dill Chervil Caraway Carrot Parsnip Celery & Celeriac 18
Risk Factors for Anaphylaxis in OAS History of anaphylaxis to related food Reactions to cooked forms Commercial SPT positive No sensitization to related pollen Established allergy to peach OAS from latex-fruit cluster (banana, kiwi) Treatment: Discuss Epipen & Pollen IT 19
20
Celery Allergy Celery is one of the most common foods to cause oral allergy syndrome in adults in countries such as Switzerland, France and Germany. Allergy to celeriac (the celery root) is more common than to celery (the stalks of the plant), but both can sometimes cause severe reactions. Symptoms vary from mild ones, such as oral allergy syndrome, to anaphylactic shock. Some reports suggest that celery spice is as likely to cause a reaction in sensitive people as raw celery. Since November 2005, food labelling rules require pre- packed food sold in the UK, and the rest of the European Union, to show clearly on the label if it contains celery 21
22
23
24
25
26
Mustard Allergy Alert - Morrisons Natural Choice Tomato & Chicken Fusiloni 5th August 2008 In the UK Morrisons are recalling their Natural Choice Tomato & Chicken Fusiloni.. As a result of a production error, the wrong sauce has been used within the product, and contains a mustard ingredient which has not been listed as an allergen on the pack. Spices 27
Baby Food Label No artificial colourings or flavourings Gluten free Egg free Wheat free Dairy free Soy free Peanut free No fillers or thickening agents No artificial preservatives Naturally tasty, no added salt or sugar 28
Baby Food Vegetables (Potatoes, Tomatoes, Sweetcorn,, Carrots, Pumpkin, Onion), Water, Lamb s s Liver, Maize Thickener (1422), Bacon (Contains Soy) Ground Rice, Spice Extract Ingredients: Water, Organic Carrots, Organic Tomato Paste, Organic Cheddar Cheese (Pasteurized Organic Whole Milk, Cheese Culture, Enzymes) Organic Spaghetti (Organic Whole Wheat Durum Flour), Organic Whole Wheat Flour, Organic Onions, Organic Garbanzo Beans. Ingredients Water, Vegetables (21%) (Yellow Split Peas, Carrots (7%), Onion, Potatoes (2.5%) Chicken (12%), Rice Noodles (7%), Maize Thickener (1422), Herb Extract, Pepper Ingredients Water, Vegetables (24%) (Carrots, Potatoes, Yellow Split Peas), Lamb (10%), Maize Thickener (1422), Maize Polenta, Ground Rice, Herb Less well known Mustard Allergy Mustard allergens are heat-resistant and resistant to enzymatic degradation, and therefore are not markedly affected by food processing. In a study in France mustard is the fourth most important food allergen for children, after eggs, peanuts, and cow milk. Since November 2005 food labelling rules in the European Union requires labelling of mustard. 29
Mustard Allergy in France In study of near fatal anaphylaxis in France Celery 30% Crustacea 17% Fish 13% Peanuts 12% Mango 6% Mustard 3% Study of anaphylaxis in children in France Egg 35% Peanut 24% Cow s s milk 8% Mustard 6% Features of Mustard allergy in children in France 53.3% started under age of 3 years Atopic eczema in 51.8% Urticaria (hives) & swelling 37% Mustard in commercial baby foods 3 infants breastfed until 11m & never consumed mustard had +ve+ SPT to mustard aged 12-18m 18m 30
Update on Food Allergy Food Allergen Bureau Vincent St Aubyn Crump FRCP(UK), FRACP Auckland Allergy Clinic October 14, 2008 31