Geographical and Cultural Food-related Symptoms, Food Avoidance and Elimination

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1 Geographical and Cultural Food-related Symptoms, Food Avoidance and Elimination Sheila E. Crowe, MD, FRCPC, FACP, FACG, AGAF Digestive Health Center of Excellence University of Virginia

2 Adverse Reactions to Food Every patient with GI symptoms assumes it is something that they ate, or did not eat, that caused the problem!

3 Adverse Reactions to Food (ARF) Food allergy or hypersensitivity: Immediate hypersensitivity Allergic eosinophilic gastroenteritis Food protein induced enterocolitis syndromes (FPIES) Celiac disease Food intolerance (non-immune): Food toxicity or food poisoning Anaphylactoid (pseudo-allergic) Pharmacologic Metabolic Idiosyncratic Psychologic Bischoff & Crowe, Gastroenterology, 128: 1089, 2005

4 Food Toxicity or Poisoning Staphylococcal enterotoxins Shigella, Salmonella, Campylobacter E. coli Hepatitis A Vibrio A severe episode of food poisoning may lead to subsequent food avoidance Post-infectious functional gastrointestinal disorder may ensue with associated food intolerances

5 Pharmacological Food Reactions Histamine» swiss cheese» tuna Amines Caffeine Sulfites Tartrazine MSG

6 Physiological Food Reactions Large volume meals cause distension, promote regurgitation Fatty foods delay gastric emptying, alter motility Legumes, cruciferous vegetables, garlic, onions, etc, may lead to flatus Non-absorbable or poorly absorbed sugars and carbohydrates can cause diarrhea, bloating, flatulence, etc

7 Mechanical Problems with Food Medical conditions in which foods can be problematic: Strictures Gastric outlet problems Gastroparesis Diverticulitis, but not diverticulosis Foods that can cause problems: Insoluble fibers skins or peel, seeds, nuts, many vegetables Beliefs regarding foods that lead to diverticulitis lead to unfounded dietary restriction

8 Psychological Food Reactions Taste aversion Texture aversion Secondary to a traumatic experience (abuse, neglect, food poisoning) Fear of the consequences of eating (bloating, flatulence) Conditioned responses (immunophysiological) Eating disorders

9 Immunological Reactions to Food Food hypersensitivity (IgE-mediated) Celiac disease Food protein enteropathies» Hypersensitivity» Immune complexes» T-cells

10 Incidence of ARF Many report adverse reactions to food but most involve non-immune mechanisms Individuals with functional disorders more likely to report adverse reactions to foods and drugs (Aliment Pharmacol Therapeutics, May 2002) Actual incidence of food allergy unknown Estimate: 1-4% of adult population Higher in children (4-8%), atopic individuals Increasing in developed nations

11 GI Disorders and ARF GI food allergy Food protein enteropathies (milk, soy) Celiac disease Eosinophilic gastroenteritis Lactose intolerance Irritable bowel syndrome and other FGID Inflammatory bowel disease Dyspepsia, GERD, peptic ulcer

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13 Common Food Allergens: Global Variation Peanuts* Tree nuts Cows milk protein (casein, BLG) Eggs Wheat * Most prevalent in North America Soya protein Corn Shellfish Sesame More common in Scandinavia # Most common in the Middle East Bischoff & Crowe, Gastroenterology, 128: 1089, 2005

14 Risk of Anaphylaxis Food allergy is now the major cause of anaphylaxis in western countries Those with increased risk include those: with past history of anaphylaxis with reactions with respiratory tract symptoms with reactions to peanuts, tree nuts, fish, seafood taking B-blockers or ACE inhibitors

15 Peanut Allergy Increasing prevalence Occurs in 1 in individuals Varying presentations Major cause of anaphylaxis Varying dose sensitivity Most react on first recognized exposure Up to 20% may lose sensitivity Associated with other food allergy, atopy

16 Oral Allergy Syndrome Initial sensitization to pollens results in IgE that cross reacts with fruit and vegetables Those with seasonal allergic rhinitis are at increased risk Pollen-food associations: Birch pollen apple, peach, pear, almond, hazelnut, potato, carrot Ragweed pollen melons, banana, gourd family Mugwort pollen celery, carrot, spices Grass pollen - tomato

17 Latex Food Allergy Syndrome Sensitization to latex results in IgE that cross reacts with fruit and vegetables Exposure to foods give same symptoms as latex Natural Rubber Latex contains over 200 proteins, 10 bind IgE (HEV b 1-10) Food associations: Kiwi (5) Potato, tomato (7) Avocado, chestnut, banana (6)

18 Lactose versus Dairy Intolerance Most common ARF worldwide Congenital deficiencies - rare Constitutional lactase insufficiency» Common in native NA, Asians, Africans, those from Mediterranean areas Secondary lactase insufficiency» Gastroenteritis, Crohn s disease, celiac disease Yoghurt, hard cheeses are lactose-free Triacylglycerol content of many milk products can cause GI symptoms unrelated to lactase insufficiency or cows milk protein (CMP) allergy

19 Adverse Reactions to FODMAPS Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols» Fructose and fructans» Sorbitol» Sucrose» Lactose

20 ARF and IBS Controversial area with studies for and against a role for food allergy in IBS Most patients have food intolerance with nonspecific reactions to food Presumed neurohormonal mechanisms

21 Between Celiac Disease & Irritable Bowel Syndrome: The No Man s Land of Gluten Sensitivity Verdu et al, Am J Gastroenterol, 104:1587, 2009

22 Conclusions and Recommendations Food intolerances are commonly reported although data for most areas of the world is lacking Food allergy is increasing in prevalence in industrialized nations Personal and cultural beliefs and experiences are important in food elimination or avoidance but few studies address these issues Imbalance worldwide between haves and have nots and dietary practices