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
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
3
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
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
6
Signs and Symptoms of Food Sensitivities
– 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
7
Signs and Symptoms of Food Sensitivities
– Respiratory tract:
• Stuffy nose
• Runny nose
• Itchy, watery eyes
• Difficulty breathing, speaking, or swallowing
• Throat tightening
• Chest tightening
8
Signs and Symptoms of Food Sensitivities
Other organ systems:
– Drop in blood pressure
– Rapid heart rate
– Anxiety; sense of doom
– Faintness
– Paleness
– Loss of consciousness
9
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
10
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
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
12
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
13
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
14
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
15
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
16
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
17
Exercise 1 : Signs and Symptoms
Questionnaire
18
IDENTIFYING THE CULPRITS
Tests
Primary Requirement
Accurate 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
20
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 cells
Skin 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
21
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
 fish
 tree nuts
 milk
 wheat
 peanut
22
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 (nonimmune-mediated reactions)
– “Skin tests for food allergy are especially
unreliable because of the large number of
false positive and false negative
reactions”
_________
David 1993
23
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
24
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
25
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
26
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
27
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.
28
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
29
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.
30
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
31
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
32
Legumes
Code
Name
Latin name
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
33
Mollusks
Code
Name
Latin name
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
34
Milk & constituents
Code
Name
Latin name
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.
35
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
36
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
37
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
38
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)
39
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
40
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
41
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
42
Identifying the Culprits
Elimination and Challenge
Elimination and Challenge
• 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
44
Elimination and Challenge
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
45
Exposure Diary
(continued)
– all symptoms experienced graded on
severity:
 1 (mild);
 3 (moderate)
2 (mild-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?
46
Exercise 2:
Food Record
Symptoms Record
47
Food Intolerance: Clinical Diagnosis
Elimination Diet: Avoid Suspect Food
Increase Restrictions
Symptoms Disappear
Symptoms Persist
Reintroduce Foods Sequentially or Double-blind
Symptoms Provoked
Diagnosis Confirmed
No Symptoms
Diagnosis Not Confirmed
48
Elimination Diet
Based 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
49
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
50
Conditions that suggest Specific Food
Involvement:
Infant eczema
– Egg
– Milk proteins
– Peanut
– Soy
– Shellfish
– Less frequently:
• Tomato
• Green pea
51
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
52
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
Others
Spices
(unspecified)
“Tree nuts”
(species
unspecified)
53
Latex-Food Syndrome:
Foods with allergenic structures similar to latex
Fruit and Vegetables
Avocado
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
54
Foods with Allergens Similar to Latex: PEN Pathway
Category
Food
Type III
Clinical findings
Identification of cross-reactive allergens
Avocado
Banana
Bell pepper
Cassava
Celery
Cherimoya
Chestnut
Custard apple
Kiwi fruit
Mango
Papaya
Passion fruit
Potato
Tomato
Chestnut
Pistachio
Walnut
Type II
Clinical findings
Characterization of cross-reactive components by
extract inhibition assays
Fig
Melon
Peach
Pineapple
Turnip
Zucchini
Type I
Clinical findings only
Apple
Apricot
Aubergine (eggplant)
Carrot
Cherry
Coconut
Loquat
Spinach
Strawberry
Watermelon
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
56
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
57
Conditions that suggest Specific Food
Involvement:
Eosinophilic esophagitis:
Abnormal number of eosinophils in the esophagus
Foods most frequently implicated
• 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
Foods most frequently implicated
•
•
Cow’s milk
Soy proteins
Most frequently develops within the first 60 days of life
Is a non-IgE-mediated condition
Conditions that suggest Specific Food Involvement:
Celiac disease (gluten-sensitive enteropathy)
Offending Foods and their derivatives
• Wheat
• Rye
• Barley
• And in some cases Oats
60
Conditions that suggest Specific Food
Involvement:
Histamine intolerance:
Histamine-containing and Histamine-releasing foods
Animal
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
Vegetable
Additives
Citrus fruits
Berries
Raisins
Cherries
Apricots
Pineapple
Prunes
Dates
Currants
Grapes
Tomato
Spinach
Eggplant
Pumpkin
Soy
Red beans
Olives
Avocado
Tartrazine
Benzoates
Sulphites
Other
Cinnamon
Cloves
Anise
Nutmeg
Vinegar
Tea
Chocolate
Colas
Alcoholic
and
dealcoholise
beverages
61
Basic Hypoallergenic Elimination Diet
• Only listed foods are allowed
• No vitamin supplements or non-essential medications
• GRAINS:
• FRUITS:
• VEGETABLES:
• MEAT:
Rice
Tapioca
Pears; pear juice
Cranberries; cranberry juice
Squash (all varieties)
Carrots
Parsnips
Lettuce
Lamb
Wild game
Turkey
62
Basic Hypoallergenic
Elimination Diet
• MEAT
SUBSTITUTES:
Lentils
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)
63
Exercise 3: Determining the Appropriate
Elimination Diet
64
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
65
Expected Results of Elimination
Diet
• Symptoms often worsen on days 24 of elimination
• By day 5-7 symptomatic
improvement is experienced
• Symptoms disappear after 10-14
days of exclusion
66
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
67
Food Challenge Record: Seattle Lab
Metabisulfite
Table 1 Schedule
Dose
Number
1
2
3
4
5
6
7
Amount
(mg)
0.1
0.5
1.0
5.0
10.0
15.0
25
Dose
Number
8
9
10
11
12
13
Amount
(mg)
Placebo
50
75
100
150
200
68
Table 2 Results
Challenge 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 eyes
Plugged 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 good
No reactions
10.45
107/72
75
Patient feels good
No 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 good
No significant numbness of upper lip
Spirometric measurements for pulmonary function performed during and
after all challenges were normal: No breathing impairment
Conclusions: Reaction to bisulfite is ruled out
69
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)
70
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
71
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
72
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
73
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
74
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)
76
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
77
Examples of Foods in Each Major Food Category:
Grains
•
•
•
•
•
•
•
•
•
•
•
Wheat
Rye
Oats
Barley
Rice
Corn
Amaranth
Quinoa
Buckwheat
Millet
Varieties and derivatives of wheat, such as:
–
–
–
–
–
Spelt
Kamut
Bulgur
Triticale
Semolina
78
Examples of Foods in Each Major Food Category:
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
Examples of Foods in Each
Major Food Category:
Fruit
Berries:
Strawberry
Raspberry
Blueberry
Cranberry
Blackberry
Others
Stone fruits:
Peaches
Apricot
Nectarines
Cherries
Plums
Others
Melons:
Cantaloupe
Honeydew
Watermelon
Others
Apple
Pear
Rhubarb
Grape
Citrus Fruits:
Orange
Grapefruit
Lemon
Lime
Tropical fruits:
Pineapple
Mango
Papaya
Passion fruit
Lychee
Longon
Star fruit
Dragon fruit
80
Examples of Foods in Each Major Food Category:
Vegetables
Green leafy vegetables, e.g.: Green, red, yellow peppers
Lettuce
Squashes of all types
Chard
Onions
Spinach
Garlic
Broccoli
Tomatoes
Beans:
Carrots
Green
Beets
String
French
Radishes
Runner
Cauliflower
Yellow wax
Asparagus
Peas
Eggplant
Green peas
Sugar peas
81
IMPORTANT NUTRIENTS IN COMMON ALLERGENS
Vitamins
M
I
L
K
E
G
G
A
+
+
Biotin
+
+
Folacin (Folate; Folic acid)
+
+
B1 (Thiamin)
B2 (Riboflavin)
+
B3 (Niacin)
B5 (Pantothenic acid)
+
B6 (Pyridoxine)
B12 (Cobalamine)
P
E
A
N
U
T
S
O
Y
F
I
S
H
W
H
E
A
T
R
I
C
E
C
O
R
N
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
D
+
+
+
E (alpha-tocopherol)
+
+
K
+
+
+
+
+
+
+
+
+
C
+
+
+
82
IMPORTANT NUTRIENTS IN COMMON ALLERGENS
Minerals
M
I
L
K
Calcium
+
Phosphorus
+
E
G
G
P
E
A
N
U
T
S
O
Y
+
F
I
S
H
W
H
E
A
T
+
+
+
+
+
+
Iron
+
+
+
Zinc
+
+
+
+
+
+
+
+
Magnesium
Selenium
Potassium
+
+
+
Molybdenum
Manganese
C
O
R
N
+
+
+
+
Chromium
Copper
R
I
C
E
+
+
+
+
+
83
Invitation to Further Information
www.allergynutrition.com
Joneja, J.M.Vickerstaff
Dealing with Food Allergies
Bull Publishing Company, Boulder,
Colorado. 2004
84