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Adverse Food Reactions & Inflammation Understanding the Connection and Empowering Patients to Heal from the Inside Out BY ERIN PEISACH, RDN, CLT OWNER OF Objectives Briefly review the immune system as it relates to inflammation. Highlight the connection between inflammation, adverse food reactions (AFR), and disease. Explain various types of AFRs, emphasizing immunemediated reactions, and review diagnostics, symptoms and treatment options. Outline the tools RDNs may provide their patients with AFRs to help reduce inflammation, improve symptoms, and promote the healing process. Review an AFR case study. The Immune System Purpose of The Immune System: Immune cells and other components fight invaders to keep the body healthy and safe Invaders: bacteria, viruses, parasites, & food Military Personnel: My Kindergarten take on the topic • White Blood Cells: • • Antibodies: • • Mast cells, basophils, eosinophils, lymphocytes, neutrophils, monocytes, macrophages, T-cells, NK-cells IgE, IgG, IgM, IgA, IgD Complement System: • C3, C4 • Platelets • Chemical Mediators • Histamine, prostaglandins, serotonin, cytokines, leukotrienes, etc. Immune System 101 Innate Involves First barriers line of defense Adaptive Prevents indiscriminate responses to harmless antigens Long lasting defense Gut Immunology GI tract has two major roles: Digestion nutrients and absorption of Immune homeostasis Constantly exposed to chemicals, proteins, bacteria, & antigens Separates the external environment from the internal environment The gut ultimately must decide: friend or foe? Gut Immunology Gut associated lymphoid tissue (GALT): Aka The Gut Immune System Largest immune organ in the body Definitions: Intestinal barrier: is a functional entity separating the gut lumen from the inner host Intestinal permeability: a functional feature of the intestinal barrier at given sites Normal: stable permeability found in healthy individuals with no signs of intoxication, inflammation or impaired intestinal functions Impaired: a disturbed permeability being non-transiently changed compared to the normal permeability leading to a loss of intestinal homeostasis, functional impairments and disease Bischoff et al. BMC Gastroenterology 2014 14:189 Intestinal Permeability Impaired intestinal barrier integrity in the colon of patients with irritable bowel syndrome: involvement of soluble mediators. – 2008 study in BMJ Conclusions: “Our study shows that colonic soluble mediators are able to reproduce functional (permeability) and molecular (ZO-1 mRNA expression) alterations observed in IBS patients.” Healthy Digestive Pathway Digestion of food begins in the mouth, then travels to the stomach Food/proteins interact with gastric acid and enzymes, turning into smaller particles ready for absorption Once the particles (antigens) pass the epithelium barrier, the immune system typically expresses oral tolerance The GALT is tightly regulated to prevent excessive immune responses Oral Tolerance Definition: Active systemic suppression of cellular or humoral immune responses to an antigen following prior administration of the antigen by the oral route Impacted by: Antigen specific elements Age Genetics Intestinal microbial environment Changes throughout the lifetime Loss of oral tolerance triggers immune reactions that may cause adverse food reactions and pathological conditions Inflammation Inflammation- to set on fire (Latin) Acute inflammation Natural and essential for health Defend, fight, repair, & heal Caused by short term injury Tissue injury, infections, immune reactions Symptoms: heat, redness, swelling, pain, loss of function Chronic inflammation Long term damaging to health Related to disease, illness, and reduced quality of life Caused by on-going injury SAD diet, nutrient deficiencies, obesity, stress Symptoms: chronic pain, allergies, fatigue, altered blood sugar, cancer Inflammation & Disease Metabolic: • Metabolic Syndrome • Obesity • Type 1 Diabetes • Type II Diabetes Pulmonology • Asthma • Anaphylaxis Musculoskeletal: • Fibromyalgia • Rheumatoid Arthritis • Reactive Arthritis • Chronic Fatigue Syndrome Dermatological: • Atopic Dermatitis • Dermatitis Herpetiformis • Urticaria • Psoriasis Neurological: • Migraine • ADD/ADHD • Autism Spectrum Disorder • Epilepsy • Depression • Insomnia • Multiple Sclerosis Gastrointestinal: • Cyclic Vomiting Syndrome • Functional Diarrhea • Irritable Bowel Syndrome • Lymphocytic Colitis • Crohn’s Disease • Ulcerative Colitis Urology • GERD • Interstitial • Celiac Disease Cystitis • Systemic Lupus Endocrinology • Hashimoto’s • Grave’s Disease Steps to Consider to Reduce Inflammation: Identify inflammatory triggers Remove triggers Heal the gut & boost the immune system Reduce inflammation Support sustained improvement in disease, illness & symptoms Inflammatory Triggers Psychological Environmental Sedentary lifestyle, tobacco/drug/alcohol use, lack of sleep Dietary choices Mold, pollution, lack of outdoors/sunlight, allergens, toxin exposure Lifestyle Choices Stress, depression, anxiety Adverse food reactions, inadequate nutrient intake, excessive intake of poor quality/processed foods Other Overweight/obesity, genetic predisposition How Food Sensitivities Cause Inflammation There is a strong connection between gastrointestinal health, immune system function, inflammation, and adverse food reactions. Adverse Food Reactions Adverse Food Reactions (AFR): AFR Toxic Non Toxic Food Contaminant Immune mediated Allergy Sensitivity Celiac Non-immune mediated Intolerance Aversion Irritants Histamine Lectins SIBO/Dysbiosis Enzyme Deficiencies NonImmunologic Reactions Malabsorption (FODMAPS) Toxic Reactions IMMUNE REACTIONS ALLERGIES TYPE 1 Antibody mediated (IgE) SENSITIVITIES TYPE 3 Antibody Mediated (IgG, IgM) TYPE 4 Cell Mediated Food AllergyType 1 Hypersensitivity Food Allergy Impacts ~6% of children and 3.7% of adults Risk factors: family history male sex genetic polymorphisms early infectious exposure rural upbringing with exposure to animals and livestock (protective) pathogenic microorganisms gut mucosa antigenic characteristic of food proteins (size, abundance, resistance to acidic and enzymatic denaturation and digestion, immunogenicity) sanitary living No prevention strategies known at this time Food Allergy Most common allergens (accounts for >90% of cases in children): Hen’s egg Cow’s milk Peanuts Soybean products Wheat Tree nuts Fish Shellfish Food Allergy Symptoms Skin- itching, hives, angioedema, flushing GI- oral itching, nausea, vomiting, diarrhea Nasal/respiratory tract- nasal congestion, runny nose, itchy eyes/nose, sneezing, laryngeal edema, wheezing, shortness of breath Cardiovascular system- light headedness, syncope, hypotension Oral Allergy Syndrome Most common food allergy in adults Examples: birch-fruit/veggie, celery-birch-mugwort, ragweed-melon/banana Generally more mild symptoms primarily in the oropharynx Lip/mouth itching, swelling, hoarseness, rhinitis, etc. Food Allergy- Testing Begin assessment with thorough clinical history and physical exam Patient will typically report reproducible symptoms occurring after exposure to a food In vivo testing (SPT/Scratch test): skin test Oral Food Challenge The definitive, gold standard test In vitro testing (RAST/ELISA): blood test Food Allergy- Treatment Remove food from the diet completely, including cross contamination exposure Consider oral food challenge (ideally double-blind, placebocontrolled) Weigh the risks (anaphylaxis, other symptoms) and benefits (nutritional, social, quality of life) Medical supervision Protocol: 1-6 weeks (varies based on severity) elimination followed by monitored/controlled food reintroduction Limitations: concerns about safety, time, reimbursement, lack of space/time Food SensitivityType III & IV Hypersensitivity Food Sensitivity Type 3 & 4 immune-mediated reaction Develops after loss of oral tolerance No set list of common reactive foods Dose-dependent reaction Delayed reaction time (4-72 hours post-ingestion) Patient is likely to have more than one reactive food (typically 1020) Symptoms vary- impact the body anywhere blood flows Difficult to identify/diagnose- more research is needed Food Sensitivity (FS) May be associated with: Intestinal dysbiosis Increased gut permeability Stress Anxiety/depression Immunological and local factors FS Symptoms Systemic symptoms Patients typically report multiple symptoms Food Sensitivity- Testing No test is currently supported by strong evidence ELISA IgG or IgG4 Antibodies Quantifies the level of IgG response to specific foods Tests foods only, not food chemicals Elevated IgG may be harmful or protective Antigen Leukocyte Cellular Antibody Test (ALCAT) End-point blood test that quantifies mediator release (i.e. histamine, cytokines, prostaglandins, etc.) Tests both foods and food chemicals Poor split sample reproducibility, low accuracy, outdated technology Mediator Release Test (MRT) Similar, but updated ALCAT technology Tests both foods and food chemicals 94.5%sensitivity, 91.7% specificity (high accuracy) and >90% split sample reproducibility (high reliability) “ Food specific IgG antibodies in serum are not of clinical importance but merely indicate a previous exposure to the food.” -Krause’s Food Nutrition and Diet Therapy 2008 IgG “is a marker of exposure and tolerance to food…” -Canadian Society of Allergy and Clinical Immunology “…the direct clinical meaning of food IgG testing is not known. The industry needs more extensive clinical research in this area.” -Aristo Vojdani, PhD, MSc, CLS, Alternative Therapies 2015 How MRT Works Food Sensitivity- Treatment Elimination Diet (at least two weeks) Specific Foods Low FODMAPS, gluten, dairy, nightshades, soy, etc. Oligoantigenic/Selected Foods LEAP protocol Elemental Oral Food Challenge Heal/repair the gut Rotation Diets? Examples of Elimination Diets Rowe Elimination Diet: Institute of Functional Medicine Diet: avoid gluten, corn, soy, dairy, shellfish, beef, pork, peanuts, eggs, oranges, refined sugar Lifestyle Eating And Performance Diet (LEAP) 5-10 foods only 6 Phase-diet based on results of MRT testing and clinical history SWAG Diet: Commonly Eliminated Foods Fatty meats: beef, pork, veal Eggs Dairy and products made from dairy Gluten and products made from gluten Corn and products made from corn Alcohol/Caffeine Foods containing yeast or promoting yeast overgrowth: processed foods, refined sugar, cheese, peanuts, vinegar Simple carbohydrates: sugar, “white” flour, processed foods, soda Unhealthy fats: margarine, shortening, butter Peanuts Strawberries and citrus fruit Foods with high FODMAPs: apples, onions, dairy, legumes, etc. Additives and preservatives Soy and products made from soy Summary of Immune-Mediated AFRs Food Allergy Food Sensitivity What Is It? Generally Quick Immune Reaction That Results in Hives, Asthma, Swelling of Airways, Vomiting Often Delayed Immune Reaction That Results In Chronic Health Problems Like IBS & Migraine Headaches Unique Characteristics: Quick Reaction Anaphylactic Shock Single Mechanism (IgE) Delayed Reaction Can Be Dosage Related Multiple Mechanisms Difficult to Identify Culprits Cells Involved in Reaction: Mast Cells Possibly Basophils T-Cells NK Cells Neutrophils Monocytes Eosinophils Basophils Platelets Mechanisms Which Trigger Mediator Release: IgE IgG, IgM, IgA C3, C4 Immune Cells Lectins Toxins Dietitian Toolbox Toolbox: 1. Help the patient identify inflammatory triggers/problematic foods 2. Design a systematic and effective elimination diet 3. Assess patient progress over time 4. Continue to help the patient heal, repair, and relieve inflammation through nutrition and lifestyle interventions 1. Help the patient identify inflammatory triggers Complete a thorough clinical and family history Review the patient’s food and symptom diary Request appropriate testing as needed Food Sensitivity? MRT Food Intolerance? Breathe Test Food Allergy? IgE skin prick or blood test 2. Design a systematic and effective elimination diet Decide on the optimal dietary plan Will the patient comply? How severe are their symptoms? What previous diets have they tried? Create a systematic approach Stay organized Avoid conflicting advice (i.e. FODMAP lists, elimination protocols, celebrity diet-gurus, etc.) Be direct, yet flexible LEAP Elimination Diet 20-25 of the best and “safest” foods for ~14 days (Phase 1) Patient agrees to consume the food and has consumed the food previously No intolerances to the food Food must be accessible and nutritionally valuable Progress the diet systematically after significant symptom improvement is reported/documented. Foods to progress the diet can be based on: Specific food preferences/accessibility Nutritional value Likelihood of tolerance Slowly- one new food every day or even every week Document the “oral food challenge” in a food/symptom diary Example: Input TESTED foods into each of the 5 phases Each food listed can be consumed in any “form” (i.e. apples, applesauce, apple juice, apple cider vinegar, etc.) Each phase, beyond phase 1 lasts at minimum 5 days Untested foods will be reintroduced after phase 5 The entire process may take >2 months Food & Symptom Diary Monitor adherence to the diet Keep the patient engaged and accountable Track even minute changes over time Detective Work! Date/Time Meds/ supplements taken Food Eaten, Amounts and Description: brand preparation, etc. Symptoms? What and how severe (1-10) Cytokine Profile of Individual D-IBS Patient IBS-D PATIENT PLASMA CYTOKINES DURING D-EPISODE v BETWEEN EPISODES 350 1 IL-2 2 IL-4 300 3 IL-6 4 IL-8 250 5 IL-10 200 pg/ml Series1 Series2 Series3 150 6 GM-CSF 7 IFN-g 8 TNF-a 9 IL-1b 100 10 IL-5 11 IL-7 50 12 IL-12 13 IL-13 0 1 2 3 4 5 6 7 8 9 10 11 12 See Specific Cytokine Key Patient on LEAP diet Patient off LEAP diet 13 14 15 16 14 IL-17 15 G-CSF 16 MCP1(MCAF) 3. Assess patient progress over time Baseline- report symptoms over the previous month (0-4 rating) Follow up- after 2 weeks on the program, monthly basis thereafter Record progress *Patients tend to “forget how they felt” so you must remind them! 4. Help the patient heal, repair, and relieve inflammation AFRs are just ONE piece of the complex inflammation puzzle Address other underlying inflammatory triggers Develop a sustainable, healthy, anti-inflammatory maintenance plan Varied, balanced diet Modify food preparation techniques, food quantity, and intake frequency Weight management as needed Nutritional supplements as needed Anti-Inflammatory Recommendations: Fats Omega 3s, monounsaturated fats Avoid fried foods and hydrogenated fats Whole foods Antioxidant/colorful foods, herbs, spices High fiber Reduce intake of processed foods Physical activity Avoid a sedentary lifestyle 10,000 steps per day Flexibility, strength, aerobic exercise Sleep 7-9 hours of good quality sleep Nap as needed Reduce toxin exposure Limit caffeine and alcohol Live a “natural” life Stress management Practice mindfulness each day Drink plenty of purified water Achieve a healthy weight Case Study- MC 53 year old female, works as a librarian Medical History: allergies, menopause, chronic low back pain, joint pain, IBS Medications: albuterol, bupropion, Allegra, Flonase, D3 1000 BMI= 25.26, overweight Generally appears healthy, exercises regularly, sleeps well, manages stress MC’s Health Goals: improve pain, reduce allergic-type symptoms, improve digestive health Case Study- MC Diet description: low carb, high protein (fish, chicken, eggs), limits dairy, frequent consumption of fresh greens, 3 glasses of wine 2-3x per week, 1-2c coffee daily No known food allergies, but avoids wheat, hot peppers and cucumbers related to digestive concerns Symptoms: sinus congestion/cough/itchy eyes despite year round use of Allegra, daily gas and bloating, heartburn, fatigue, headache, others… Initial Symptom Survey= 69 Intervention: Start with specific food elimination diet: gluten, dairy, sugar, soy Assess progress. If limited improvement, try olio-antigenic diet (LEAP) based on MRT results Case Study- MC INPUT results Case Study- MC Phases 1-5 Phase 1: 2 weeks, baseline diet Phases 2-5: minimum of 5 days each Add 1 new food each day (or slower!) Use the food plan to develop a menu plan: B: Hot quinoa flakes in soy milk, add maple syrup, chopped walnuts, and sliced strawberries. Seltzer water with a few raspberries. S: Hard-boiled egg L: Steamed shrimp over cooked quinoa or amaranth, with a side of blanched string beans, toss in sesame oil and toasted sesame seeds. S: Dry roasted or steamed edamame D: Baked tofu (marinade in tamari, turmeric, tahini paste, oil). Side of roasted yellow squash. S: Hot chocolate- heat up hazelnut or soy milk add carob powder & maple syrup Case Study- MC Follow up #1: Avoided all yellow and red MRT foods for 1 week, followed by… LEAP phase 1 for 2 weeks Lost 6.6lb without limiting food quantity or exercising Follow up SS total= 33 (Initial SS= 69, improved by 36 points in 3 weeks) Follow up #2: Started probiotic (boost immune health) and curcumin (anti-inflammatory for joint pain) LEAP phases 2-5 for 1 month Lost 1 additional pound Follow up #2 SS= 21 (improved by 12 additional points in 4 weeks, 48 total points) Added in additional anti-inflammatory compounds: omega 3 fish oil, OPC-Sorb (antioxidant blend for pain) My Own Testimonial R-arm, eczema flare up R-arm, after following LEAP elimination for 1 month Conclusion Inflammation, adverse food reactions, and chronic disease are interrelated and may be present in your patients. By understanding various types of AFRs you will be able to better identify problematic foods and provide the appropriate dietary intervention. Primum non nocere- first do no harm. Short-term elimination diets are typically not harmful and may potentially change someone’s life! Help your patients to heal from the inside out, supporting them through every step of the process. References 1. Food Allergy: Adverse Reactions to Foods and Food Additives, Fifth Edition. Edited by Dean D Metcalfe, Hugh A Sampson, Ronald A Simon and Gideon Lack. 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. 2. Castro-Sanchez, P. & Martin-Villa, J.M. (2013). Gut immune system and oral tolerance. British Journal of Nutrition, 109, pp. S3-S11. 3. MacDonald T.T. & Monteleone G. (2005). Immunity, Inflammation, and Allergy in the Gut. Science, 307(5717), pp. 1920-1925. 4. Lied, GA. Indication of immune activation in patients with perceived food hypersensitivity. (2014). Dig Dis Sci, 59(2), 259-266. 5. LILLESTØL K, HELGELAND L, BERSTAD A, et al. Indications of ‘atopic bowel’ in patients with self-reported food hypersensitivity. Alimentary Pharmacology & Therapeutics [serial online]. May 15, 2010;31(10):1112-1122. Available from: Academic Search Premier, Ipswich, MA. Accessed March 18, 2015. 6. Thierry Piche, Giovanni Barbara, Philippe Aubert, Stanislas Bruley Des Varannes, Raffaella Dainese, et al. Impaired intestinal barrier integrity in the colon of patients with irritable bowel syndrome: involvement of soluble mediators.. Gut, BMJ Publishing Group, 2009, 58 (2), pp.196-201. 7. Pasula, Mark J.; The Patented Mediator Release Test (MRT); A Comprehensive Blood Test for Inflammation Caused by Food and Food-Chemical Sensitivities. Townsend Letter, January 2014 Thank you! Erin Peisach, RDN, CLT Nutrition by Erin, LLC 1777 Reisterstown Road, suite 118A Pikesville, MD 21208 410-635-4210 [email protected] www.nutritionbyerin.com Follow me on facebook!
