Dietetic Practice in the Management of Adverse Reactions to Foods

Dietetic Practice in the Management of Adverse

Reactions to Foods

Clinical Practice Workshops

2009-2010

Diagnosis of Adverse Reactions to Foods

Signs, Symptoms, and Differential Diagnosis

3

The Medical Paradigm

• Signs and Symptoms suggest the disease condition

• Tests are used to provide a definitive diagnosis and suggest a probable cause

• Diagnosis determines the treatment

• Treatment typically consists of:– Medications– Surgery– Other appropriate measures

Food Allergy and the Medical Paradigm

• Food does not cause allergy– The immunological or physiological response

to the food is the cause of symptoms

• The same food can trigger entirely different symptoms in different individuals, and sometimes different symptoms in the same individual– “One cause, one disease” does not apply

4

Food Allergy and the Medical Paradigm

• A specific test will not identify the cause– Most people can eat the allergenic food

without symptoms

• Food allergy treatment involves medications to control the symptoms– There is no way to stop the allergic reaction

once it has started

• Prevention involves avoidance of the allergenic food

5

6

Signs and Symptoms of Food Sensitivities

Symptoms vary from individual to individual

Sometimes symptoms vary in presentation and severity in the same individual on different occasions

• Symptoms appear in all organ systems but tend to be most obvious in:– Skin:

• Flushing• Hives• Angioedema (swelling especially of facial areas: lips, throat,

tongue)• Itching• Eczema• Rash

7


– Digestive tract:• Stomach ache• Abdominal bloating• Diarrhea• Alternating diarrhea and constipation• Nausea• Vomiting• Heart burn and reflux

– Differential diagnosis: Food sensitivity not indicated

• Weight loss• Blood in stool

8


– Respiratory tract:• Stuffy nose• Runny nose• Itchy, watery eyes• Difficulty breathing, speaking, or swallowing• Throat tightening• Chest tightening

9


Other organ systems:

– Drop in blood pressure– Rapid heart rate– Anxiety; sense of doom– Faintness– Paleness– Loss of consciousness

10

Signs and Symptoms

• Anaphylaxis– Involves all organ systems– In rare cases can proceed to cardiovascular

collapse– Has the very rare potential to proceed to fatal

anaphylactic shock– Management always involves administration

of injectable adrenalin (epinephrine) and immediate transportation to emergency medical facilities

Epipen and Twinject

• How to use injectable epinephrine (adrenalin)– http://foodallergies.about.com/od/emergencytr

eatment/ht/autoinjector.htm

• Free training kits available:– Epipen 1-877-374-7361– Twinject 1-877-894-6532

http://foodallergies.about.com/od/emergencytreatment/ht/autoinjector.htm

http://foodallergies.about.com/od/emergencytreatment/ht/autoinjector.htm

12

Signs and Symptoms• In babies and children:

– Digestive tract distress:• Abdominal pain• Spitting up or vomiting• Diarrhea• May be blood in stool

– Irritability– Difficulty sleeping– Failure to thrive– Eczema– Other rashes

13

Diagnosis of Food Hypersensitivity• The symptoms that suggest food

sensitivity may actually be caused by many different medical conditions

• Frequently the idea of food hypersensitivity is suggested when all other causes for the person’s symptoms have been ruled out

• Before food sensitivities are considered, ensure that other causes for the symptoms have been ruled out by appropriate medical investigations

14

Differential Diagnosis

• For example:– Celiac disease: high levels of:

• anti-tissue transglutaminase antibodies (tTGA)• anti-endomysium antibodies (EMA)

– Intestinal infection: stool analysis for:• ova and parasites for parasitic infestations• Clostridium difficile• Other pathogens or potential pathogens

– Inborn errors of metabolism

15

Potential Causes of Adverse Reactions to Foods

• IgE mediated food hypersensitivity – Food allergy and anaphylaxis– Oral allergy syndrome (OAS)– Latex-food syndrome

• Non-IgE mediated food hypersensitivity– Food protein enteropathies– Eosinophilic esophagitis– Eosinophilic gastroenteritis – Eosinophilic proctocolitis– Celiac disease

16

Potential Causes of Adverse Reactions to Foods

• Non-immunologically mediated food sensitivity (food intolerances)– Lactose intolerance– Sucrose intolerance– Fructose intolerance– Histamine intolerance– Sulphite sensitivity– Nickel sensitivity– Sensitivity to food additives:

• Tartrazine and other azo dyes• Benzoates

17

Treatment of Adverse Reactions to Food

• Whatever the physiological basis of the reaction, dietetic management is the same:– Accurate identification of the food

components responsible– Avoidance of the offending food ingredient– Provision of a diet that provides complete

balanced nutrition from alternative sources– Recognition of the development of tolerance

18

Exercise 1 : Signs and Symptoms Questionnaire

IDENTIFYING THE CULPRITS

Tests

20

Primary RequirementAccurate Identification of the Culprit

Foods

• There is a lack of definitive diagnostic tests for food allergies, food intolerances, and other adverse reactions to foods

• Skin tests and blood tests detect indicators of probable sensitization to an allergen – usually IgE

• They often do not identify the offending food because the mere presence of antibody to the food does not predict the response when the food is consumed

21

TESTS FOR FOOD ALLERGY AND INTOLERANCE

• Skin tests: scratch; prick; intradermal Positive response indicated by wheal and

flare reaction in the skin Size usually measured 0 - 4+ Indicate release of inflammatory

mediators, especially histamine, from skin mast cellsSkin mast cells release inflammatory mediators in response to stimuli different from those that trigger mediator release from mast cells in other body tissues - especially the digestive tract

22

Value of Skin Tests in Practice

• Positive predictive accuracy of skin tests rarely exceeds 50% (estimates 30% - 60%)– Many practitioners rate them lower

• Negative tests for some highly allergenic foods thought to have close to 100% predictive accuracy

• Such foods include: egg milk fish wheat tree nuts peanut

23

Value of Skin Tests in Practice

• Negative skin tests do not rule out the possibility of non-IgE-mediated hypersensitivity reactions

• Do not rule out food intolerances (non-immune-mediated reactions)– “Skin tests for food allergy are especially

unreliable because of the large number of false positive and false negative reactions”

_________David 1993

24

Reasons for False Positive Skin Tests

• Degranulation of skin mast cells by stimuli that do not degranulate mast cells in the digestive tract

• Differences in the form in which the food is applied to the skin compared to that which encounters immune cells in the digestive tract– antigens in fruits and vegetables change when

cooked– allergen may be derived from an unstable food

extract– digestive processes can unmask antigens

25

False Negative Skin Tests

• Children younger than 2-3 years are more likely to have a negative skin test and positive food challenge than adults

• Adverse reaction is not mediated by IgE

• Commercial allergen may contain no material that the immune system can recognize

26

Blood Tests for Food Allergy

– RAST, FAST, ELISA and others Test for the presence of anti-food antibodies Detect anti-food IgE

– The mere presence of the antibody does not indicate clinical significance

– Positive tests often do not correlate well with observed reactions when the food is eaten

27

Value of Allergy Tests in Practice

• A key message is that a positive allergy test result (skin or blood) indicates only the presence of allergen specific IgE (called sensitization)

• It does not necessarily mean clinical allergy (ie, allergic symptoms with exposure).

• It is important for this reason that the allergy evaluation be based on the patient's history and directed by a health care professional with understanding of allergy

____________Cox et al 2008

28

Use of the Information

Use the information obtained from evaluation of the patient to determine:

• which allergy diagnostic tests to order

• how to interpret the allergy diagnostic test results

• how to use the information obtained from the allergy evaluation to develop an appropriate therapeutic treatment plan.

29

Which Tests Should I Order?

• Allergen-specific IgE tests are carried out by a variety of approved methods in Canada

• Provincial medical plans usually pay for 5 tests per person per year

• Order “food mixes” for the initial five tests• If any are positive the lab will test individual

foods within the groups at no additional charge• Do not advise patient to avoid all the foods in the

positive mix without further investigation

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Examples of Blood Tests for allergen-specific IgE

• Phadia UniCAP System

• This assay system can measure levels of allergen-specific IgE as low as 0.1 kU/L

• The clinical relevance of results in the range of 0.1-0.35 kU/L warrants study.

31

Which Tests Should I Order?

• Examples of food mixes:– Legume mix (peanuts, soy, beans, lentils)– Vegetable mix– Fruits mix– Grains (includes wheat)– Nut and seed mix– Animal origin foods (milk, egg, meats)– Fish mix– Mollusks and shellfish

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Example: Grains

Code Name Latin name

f6 Barley Hordeum vulgare

f310 Blue vetch Fabaceae (Leguminosae)

f11 Buckwheat Fagopyrum esculentum

f55 Common millet Panicum miliaceum

f56 Foxtail millet Setaria italica

f79 Gluten Common

f57 Japanese millet Echinochloa crus-galli

f8 Maize/Corn Zea mays

f90 Malt Hordeum vulgare

f7 Oat Avena sativa

f9 Rice Oryza sativa

f5 Rye Secale cereale

f124 Spelt wheat Triticum spelta

f4 Wheat Triticum aestivum

http://www.immunocapinvitrosight.com/dia_templates/ImmunoCAP/Allergen____28309.aspx










































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Legumes


f296 Carob bean gum Ceratonia siliqua

f309 Chick pea Cicer arietinus

f305 Fenugreek Trigonella foenum-graecum

f315 Green bean Phaseolus vulgaris

f246 Guar, Guar gum Cyamopsis tetragonolobus

f297 Gum arabic Acacia spp.

f235 Lentil Lens esculenta

f182 Lima bean Phaseolus lunatus

f12 Pea Pisum sativum

f13 Peanut Arachis hypogaea

f287 Red kidney bean Phaseolus vulgaris

f14 Soybean Glycine max (Soja hispida)

f298 Tragacanth gum Astragalus gummifer

f15 White bean Phaseolus vulgaris











































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Mollusks


f346 Abalone Haliotis spp.

f37 Blue mussel Mytilus edulis

f207 Clam Clam

f59 Octopus Octopus vulgaris

f290 Oyster Ostrea edulis

f58 Pacific Flying Squid Todarodes pacificus

f338 Scallop Pecten spp.

f314 Snail Helix aspersa

f258 Squid Loligo edulis, Loligo vulgaris




























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Milk & constituents


f78 Casein Bos spp.

f81 Cheese, Cheddar type

f82 Cheese, mold type

f2 Cow's milk Bos spp.

f231 Cow's milk, boiled Bos spp.

f236 Cow's whey Bos spp.

f300 Goat's milk

f286 Mare's milk Equus spp.

f325 Sheep's milk Ovis spp.

f326 Sheep's whey Ovis spp.









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Testing for IgG4 against foods

• Testing for IgG4 against foods is not recommended as a diagnostic tool: EAACI Task Force Report.

• Serological tests for immunoglobulin G4 (IgG4) against foods are persistently promoted for the diagnosis of food-induced hypersensitivity

• Many patients believe that their symptoms are related to food ingestion

• Tests for food-specific IgG4 represent a growing market• Testing for blood IgG4 against different foods is

performed with large-scale screening for hundreds of food items by enzyme-linked immunosorbent assay-type and radioallergosorbent-type assays in young children, adolescents and adults.

______________Stapel et al 2008

37

Value of IgG4 Tests in Practice

• Many serum samples show positive IgG4 results without corresponding clinical symptoms.

• IgG4 against foods indicates that the person has been repeatedly exposed to food components, which are recognized as foreign proteins by the immune system

• Its presence should not be considered as a factor which induces hypersensitivity, but rather as an indicator for immunological tolerance, linked to the activity of regulatory T cells.

______________Stapel et al 2008

_______________Tomicic et al 2009

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Use of IgG4 Test Results

• Food-specific IgG4 does not indicate food allergy or intolerance, but rather a physiological response of the immune system after exposure to food components.

• Testing of IgG4 to foods is considered as irrelevant for the laboratory work-up of food allergy or intolerance and should not be performed in case of food-related complaints.

______________Stapel et al 2008

39

Unorthodox Tests

• Many people turn to unorthodox tests when avoidance of foods positive by conventional test methods have been unsuccessful in managing their symptoms

• Tests include:– Vega test (electro-acupuncture)– Biokinesiology (muscle strength)– Analysis of hair, urine, saliva– Radionics– ALCAT (lymphocyte cytotoxicity)

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Disadvantages of Unreliable Tests

• Diagnostic inaccuracy

• Therapeutic failure

• False diagnosis of allergy

• Creation of fictitious disease entities

• Failure to recognize and treat genuine disease

• Inappropriate diets

• Malnutrition

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Consequences of Mismanagement of Adverse Reactions to Foods

• Malnutrition; weight loss, due to extensive elimination diets

• Food phobia due to fear that “the wrong food” will cause permanent damage, and in extreme cases, death

• Frustration and anger with the “medical system” that is perceived as failing them

• Disruption of lifestyle, social and family relationships

42

The Bottom Line

• Elimination and Challenge is the only accurate method of identifying the specific foods responsible for a person’s adverse reactions

• Suspect foods are eliminated from the diet for a specific period of time

• Challenge is conducted by reintroducing each eliminated food individually and monitoring the person’s response

Identifying the Culprits

Elimination and Challenge

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• Removal of the suspect foods from the diet, followed by reintroduction is the only way to:– identify the culprit food components– confirm the accuracy of any allergy tests

• Long-term adherence to a restricted diet should not be advocated without clear identification of the culprit food components

45


Stage 1: Exposure Diary– Record each day, for a minimum of 5-7

days:

all foods, beverages, medications, and supplements ingested

composition of compound dishes and drinks, including additives in manufactured foods

approximate quantities of each the time of consumption

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Exposure Diary(continued)

– all symptoms experienced graded on severity:

1 (mild); 2 (mild-moderate) 3 (moderate) 4 (severe)

– time of onset

– how long they last

• Record status on waking in the morning.• Was sleep disturbed during the night, and if

so, was it due to specific symptoms?

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Exercise 2: Food RecordSymptoms Record

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Food Intolerance: Clinical Diagnosis

Symptoms Disappear

Elimination Diet: Avoid Suspect Food

Symptoms Persist

Increase Restrictions

Reintroduce Foods Sequentially or Double-blind

Symptoms Provoked No Symptoms

Diagnosis Confirmed Diagnosis Not Confirmed

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Elimination DietBased on:

– detailed medical history– analysis of Exposure Diary– any previous allergy tests– foods suspected by the patient

• Formulate diet to exclude all suspect allergens and intolerance triggers

• Provide excluded nutrients from alternative sources

• Duration: Usually four weeks

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Therapeutic Diets

• Certain conditions tend to be associated with specific food components

• Suspect food components are those that are probable triggers or mediators of symptoms

• Examples:– Eczema: highly allergenic foods– Migraine: biogenic amines– Urticaria/angioedema: histamine– Chronic diarrhea: disaccharides– Asthma: cyclo-oxygenase inhibitors; sulphites

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Conditions that suggest Specific Food Involvement: Infant eczema

– Egg– Milk proteins– Peanut– Soy– Shellfish– Less frequently:

• Tomato• Green pea

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Conditions that suggest Specific Food Involvement: Adult eczema

• May start as contact allergy (atopic dermatitis)– Could be indicator of latex allergy

• May be symptom of IgE-mediated allergy to any food: – Most common foods as in infant eczema– Less common: tomato; onion

• May be exacerbated by foods high in histamine– Include histamine-restricted diet during elimination

phase*

______________

*Worm et al 2009

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Conditions that suggest Specific Food Involvement:

Oral Allergy Syndrome (OAS):Foods with allergens similar to birch pollen

Fruit

Apple

Apricot

Cherry

Kiwi fruit

Melon

Nectarine

Orange

Peach

Watermelon

Vegetables

Carrot

Celery

Fennel

Potato

Tomato

Legumes and Grains

Peanuts

Nuts and Seeds

Hazelnuts

“Tree nuts” (species unspecified)

Others

Spices (unspecified)

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Latex-Food Syndrome:Foods with allergenic structures similar to latex

Fruit and VegetablesAvocado

Banana

Celery

Citrus fruits

Eggplant

Fig

Grapes

Kiwi fruit

Mango

Melon

Papaya

Passion fruit

Peach

Potato

Pineapple

Tomato

Legumes and Grains

Peanut

Soy

Wheat

Nuts and Seeds

Chestnut

Pistachio

Walnut

Category Food

Type IIIClinical findingsIdentification of cross-reactive allergens

Avocado ChestnutBanana PistachioBell pepper WalnutCassavaCeleryCherimoyaChestnutCustard appleKiwi fruitMangoPapayaPassion fruitPotatoTomato

Type IIClinical findings Characterization of cross-reactive components by extract inhibition assays

Fig TurnipMelon Zucchini PeachPineapple

Type IClinical findings only

AppleApricotAubergine (eggplant)CarrotCherryCoconutLoquatSpinachStrawberryWatermelon

Foods with Allergens Similar to Latex: PEN Pathway

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Conditions that suggest Specific Food Involvement:Irritable Bowel Syndrome (IBS):Foods most frequently associated with symptoms

• Food allergens (individual reactivity)• Intolerance triggers

– Disaccharides (e.g. lactose; sucrose)– Monosaccharides (fructose)

• Free starches:– White flour; white rice– Root vegetables (potato; carrot)– Starchy fruits (banana)

• Raw fruits and vegetables• Processed (fermented) meats and sausages• High level of insoluble fibre (dried peas, beans; bran

from grains; whole nuts and seeds)• “Irritant” spices

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Conditions that suggest Specific Food Involvement:Eosinophilic gastroenteritis:Abnormal number of eosinophils in the stomach and small intestine

Foods most frequently implicated

• Egg• Cow’s milk• Soy• Wheat

• Peanuts• Tree nuts• Shellfish• Fish

Conditions that suggest Specific Food Involvement:Eosinophilic esophagitis:Abnormal number of eosinophils in the esophagus


• Egg • Cow’s milk• Soy• Wheat• Corn• Peanuts

• Tree nuts• Shellfish• Fish• Beef• Rye

Conditions that suggest Specific Food Involvement:Eosinophilic proctocolitis:Abnormal number of Eosinophils confined to the colon


• Cow’s milk

• Soy proteins

Most frequently develops within the first 60 days of life

Is a non-IgE-mediated condition

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Conditions that suggest Specific Food Involvement:Celiac disease (gluten-sensitive enteropathy)Offending Foods and their derivatives

• Wheat

• Rye

• Barley

• And in some cases Oats

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Conditions that suggest Specific Food Involvement:Histamine intolerance:Histamine-containing and Histamine-releasing foodsAnimal

Proteins

Eggs

Shellfish

Fish (unless freshly caught)

Processed and fermented meats and sausages

Left-over meats

Milk Products

Fermented milk products:

Cheese of all types

Yogurt

Buttermilk

Kefir

Fruit

Citrus fruits

Berries

Raisins

Cherries

Apricots

Pineapple

Prunes

Dates

Currants

Grapes

Vegetable

Tomato

Spinach

Eggplant

Pumpkin

Soy

Red beans

Olives

Avocado

Additives

Tartrazine

Benzoates

Sulphites

Other

Cinnamon

Cloves

Anise

Nutmeg

Vinegar

Tea

Chocolate

Colas

Alcoholic and dealcoholise

beverages

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Basic Hypoallergenic Elimination Diet

• Only listed foods are allowed• No vitamin supplements or non-essential medications

• GRAINS: Rice

Tapioca

• FRUITS: Pears; pear juice

Cranberries; cranberry juice

• VEGETABLES: Squash (all varieties)

Carrots

Parsnips

Lettuce

• MEAT: Lamb

Wild game

Turkey

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Basic Hypoallergenic Elimination Diet

• MEAT Lentils

SUBSTITUTES: Split pea

Garbanzo beans

(chick peas)

• FLAVOURINGS: Sea salt• BEVERAGES: Distilled water in glass containers• OILS Canola oil

Olive oil

Safflower oil• OTHER Agar-agar

(Make jelly dessert s)

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Exercise 3: Determining the Appropriate Elimination Diet

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Duration of the Elimination Diet

• The “Basic Hypoallergenic (few foods) Diet” is nutritionally inadequate and should not be followed for longer than 10 to 14 days

• A selective elimination diet with nutritionally equivalent substitutes is followed for four weeks– Four weeks seems to be optimum for remission of

symptoms and for elicitation of symptoms on challenge

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Expected Results of Elimination Diet

• Symptoms often worsen on days 2-4 of elimination

• By day 5-7 symptomatic improvement is experienced

• Symptoms disappear after 10-14 days of exclusion

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Challenge• Use incremental dose challenge (SIDC) to each

eliminated food in its purest form to determine:– immediate reaction– delayed reaction– degree of tolerance (dosage)

• Do not test any food suspected to have caused a severe or an anaphylactic reaction except under medical supervision in a facility equipped for resuscitation

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Food Challenge Record: Seattle Lab MetabisulfiteTable 1 Schedule

Dose Number

Amount (mg)

Dose Number

Amount (mg)

1 0.1 8 Placebo

2 0.5 9 50

3 1.0 10 75

4 5.0 11 100

5 10.0 12 150

6 15.0 13 200

7 25

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Spirometric measurements for pulmonary function performed during and after all challenges were normal: No breathing impairmentConclusions: Reaction to bisulfite is ruled out

Table 2 ResultsChallenge dose in gelatin capsule administered every 10 minutes

Time Blood Pressure Dose (mg) Effects Reported

9.00 100/58 0.1 Patient feels good

9.10 110/73 0.5 No reaction

9.25 112/71 1.0 No reaction

9.35 118/81 5.0 Itching eyesPlugged ears

9.45 103/81 10 Plugged ears

9.55 118/83 15 No reaction

10.05 103/69 25 Chest tightness

10.20 108/76 Placebo Tingling around mouth

10.30 110/80 50 Patient feels goodNo reactions

10.45 107/72 75 Patient feels goodNo reactions

10.55 107/72 100 No reactions

11.10 114/75 150 Numbness of upper lip and tongue

11.25 114/75 200 Patient feels goodNo significant numbness of upper lip

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Challenge

• The basic elimination diet, or therapeutic diet, continues during this phase

• For adults: – Do not add any test foods to the diet until all eliminated

foods have been tested separately, even if they produce no reaction during the challenge

• Children: – Add foods causing no adverse reaction when all tests

in a single food category have been tested (e.g. add milk when all tests in the “milk category” have been completed)

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Incremental Dose Challenge

Day 1:• Morning: Eat a small quantity of the test food

Wait four hours, monitoring for adverse reaction; if no symptoms:

• Afternoon: Eat double the quantity of test food eaten in the morning.

• Wait four hours, monitoring for any adverse reactions; if no symptoms:

• Evening: Eat double the quantity of test food eaten in the afternoon

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Incremental Dose Challenge Day 2:• Do not eat any of the test food

– Continue to eat elimination diet

• Monitor for any adverse reactions during the night and day. This may be due to a delayed reaction to the test food

• If an adverse reaction to the test food occurs at any time during the test: STOP. – Do not continue to eat the test food

• Wait 48 hours after all symptoms have subsided before testing another food

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Incremental Dose Challenge

Day 3:• If no adverse reactions have been experienced

proceed to a new food• If the results of Day 1 and/or Day 2 are

unclear :– Repeat Day 1, using the same food, the same

test protocol, but larger doses of the test food

• Day 4:– Monitor for delayed reactions as on Day 2

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Challenge Test

• Continue testing in the same manner until all excluded foods, beverages, and additives have been tested

• The first day is the test day and the second is a monitoring day for delayed reactions

Maintenance Diets

The Essentials in Providing Complete Balanced Nutrition

DIET FOR OPTIMUM NUTRITION Provide a nutritionally balanced diet that

supplies all essential macronutrients (protein, fat, carbohydrate) and micronutrients (vitamins and minerals) every day

Diets restricted because of food sensitivities:• Each meal and snack should contain three components:

1. Protein (PRO) 2. Grain (GR) or Starch (ST) 3. Fruit and/or Vegetable (FR/VEG)

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Examples of Foods in Each Major Food Category:

Protein• Meat of all types• Poultry• Fish• Shellfish• Eggs• Nuts• Seeds• Tofu• Milk

– Milk products such as:– Cheese of all types– Yogurt– Buttermilk

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Grains• Wheat • Rye• Oats• Barley• Rice• Corn• Amaranth• Quinoa• Buckwheat• Millet• Varieties and derivatives of wheat, such as:

– Spelt– Kamut– Bulgur– Triticale – Semolina

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Starches• Flours and starches derived from “Grains”• Starchy vegetables and fruits, such as:• Potato• Sweet potato• Yam• High-starch root vegetables• Lentils• Dried beans• Dried peas• Garbanzo bean (chick pea)• Lima beans• Broad beans (fava)• Cassava• Plantain• Banana 79


FruitBerries:

Strawberry

Raspberry

Blueberry

Cranberry

Blackberry

Others

Stone fruits:PeachesApricotNectarinesCherriesPlumsOthers

Melons:CantaloupeHoneydewWatermelonOthers

Apple

Pear

Rhubarb

Grape

Citrus Fruits:Orange

Grapefruit

Lemon

Lime

Tropical fruits:Pineapple

Mango

Papaya

Passion fruit

Lychee

Longon

Star fruit

Dragon fruit80


VegetablesGreen leafy vegetables, e.g.:

Lettuce

Chard

Spinach

Broccoli

Beans:Green

String

French

Runner

Yellow wax

PeasGreen peas

Sugar peas

Green, red, yellow peppers

Squashes of all types

Onions

Garlic

Tomatoes

Carrots

Beets

Radishes

Cauliflower

Asparagus

Eggplant81

MILK

EGG

PEANUT

SOY

FISH

WHEAT

RICE

CORN

A + + +

Biotin + + +

Folacin (Folate; Folic acid) + + + +

B1 (Thiamin) + + + +

B2 (Riboflavin) + + + + + +

B3 (Niacin) + + + + +

B5 (Pantothenic acid) + + +

B6 (Pyridoxine) + + + +

B12 (Cobalamine) + + +

C

D + + +

E (alpha-tocopherol) + + + +

K + + +

IMPORTANT NUTRIENTS IN COMMON ALLERGENS

Vitamins

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MILK

EGG

PEANUT

SOY

FISH

WHEAT

RICE

CORN

Calcium + + +

Phosphorus + + + + +

Iron + + + + + +

Zinc + + +

Magnesium + + +

Selenium + + +

Potassium + + +

Molybdenum +

Chromium + + +

Copper +

Manganese +

IMPORTANT NUTRIENTS IN COMMON ALLERGENSMinerals

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Invitation to Further Information

www.allergynutrition.com

Joneja, J.M.Vickerstaff

Dealing with Food Allergies

Bull Publishing Company, Boulder, Colorado. 2004

Dietetic Practice in the Management of Adverse Reactions to Foods

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