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Food Allergies and Intolerances and Their Importance to the Meat and Poultry Industry Joe L. Baumert, Ph.D. Food Allergy Research & Resource Program University of Nebraska [email protected] www.farrp.org Food Allergies The food of one may be poison for another. Lucretius De Rerum Natura Food Sensitivities (Individualistic Adverse Reactions to Foods) Food Allergy Food Intolerance Food Intolerances • Anaphylactoid Reactions • Metabolic Food Disorders • Idiosyncratic Reactions Anaphylactoid Reaction • “Anaphylactoid” ≠ “Anaphylaxis” • Certain foods can cause reactions that can mimic symptoms of allergic reactions • Probably associated with components of foods that are small in size, but none have been identified • Does this illness really exist? – ex. strawberry “allergy” Metabolic Food Disorders • Caused by exposure to a food component that is toxic to certain individuals with genetic defects in their ability to metabolize that component or • The component has an unusual effect on the host’s normal metabolism Lactose Intolerance • Associated with deficiency of intestinal lactase (bgalactosidase) • Inability to metabolize lactose • Disease worsens with advancing age • Ultimately affects 60-90% in some ethnic groups • Symptoms: abdominal pain, flatulence, frothy diarrhea • Treated with dairy product avoidance diets Treatment of Lactose Intolerance • Exclusion of all dairy products • Consumption of dairy products with low lactose levels including cheese and yogurt • Divided doses of milk • Lactose-hydrolyzed milk Idiosyncratic Reaction • An adverse reaction to a food or food component among certain individuals occurring through unknown mechanisms Some Examples of Idiosyncratic Reactions Food • Chocolate • Tartrazine • Sulfiting agents • Food colors Symptom Migraine headache Asthma Asthma Hyperkinesis Food Additives • Estimate 2,000 - 20,000 food additives • Preservatives, sweeteners, stabilizers, thickeners, colorings, flavorings, conditioners, antioxidants • Small number associated with adverse reactions Sulfites Used in Foods • Sulfur dioxide (SO2) • Inorganic sulfite salts that liberate SO2 – Na2S2O5 and K2S2O5 (metabisulfite) – NaHSO3 and KHSO3 (bisulfite) – Na2SO3 (sulfite) – can occur naturally in foods Adverse Reactions to Ingested Sulfites • Asthmatic – proven • Nonasthmatic - controversial – Hives, pruritus, angioedema, hypotension, abdominal distress – Most not substantiated by double-blind oral challenge Sulfite Sensitivity • Asthmatic reactions • Afflicts 150,000 people in U.S. (1.7% of all asthmatics) • Steroid-dependent asthmatics at greatest risk (4-7% of these people are affected) • Patients display thresholds (5-200mg K2S2O5) • Patients react to some sulfited foods but not to others • Foods having < 100 ppm total SO2 may not elicit reactions Adverse Reactions to Food Additives-Conclusions • Adverse reactions to additives are rare • Most research studies are not well-designed • Often, adverse reactions attributed to additives are due to another cause Food Sensitivities (Individualistic Adverse Reactions to Foods) Food Allergy Food Intolerance Food Allergy (Food Hypersensitivity) IgE-Mediated Cell-Mediated Exercise-induced Celiac Disease Cell-Mediated Food Allergies Delayed Hypersensitivity – Reactions typically occur 6 – 24 hours after ingestion of the offending food Celiac Disease – Celiac sprue, non-tropical sprue – Gluten-sensitive enteropathy Localized tissue damage resulting from GI tract inflammation Celiac Disease Prevalence of at least 1 per 2000 in U.S. Symptoms associated with malabsorption (body wasting, anemia, diarrhea, bone pain, etc.) – 20% do not have diarrhea symptoms Associated with consumption of gluten fractions of wheat, rye, barely, and sometimes oats Treatment: avoidance diets Long-term sequelae (e.g. lymphoma) Food Allergy (Food Hypersensitivity) IgE-Mediated Cell-Mediated Exercise-induced Celiac Disease IgE-Mediated Allergic Response: Mechanism Sensitization Phase IgE-Mediated Allergic Response: Mechanism Elicitation Phase Prevalence of Food Allergy Perceived prevalence in the U.S. – 1 in 5 Americans believe they have food allergies – Many consumers do not differentiate between IgE-mediated allergy and other food sensitivities – Also accounts for a number of consumers who experience oral allergy syndrome Oropharyngeal itching, edema, urticaria Rarely associated with systemic reactions Fresh fruits and vegetables: peaches, apples, kiwi Prevalence • Between 3.5-4% of the U.S. population (or 1012 million Americans) have food allergy – Sicherer, et al. J. Allergy Clin Immunol. 1999;103:559-62. – Sicherer, et al. J. Allergy Clin. Immunol. 2004;114:159-165. Prevalence of Specific Food Allergies in the U.S.* Crustacean shellfish Peanut Tree nut Fish - *Based on FAAN telephone surveys 1.9% 0.6% 0.5% 0.4% Prevalence of True Food Allergies Infants/young children Adults - 4-8% 2-3% Natural History of Food Allergy • Most infants outgrow their allergy within months • Especially true if food allergy occurs before 3 years of age • Some food allergies (ex. peanuts) are more persistent than others (ex. milk, eggs) Factors Involved in Development of IgEMediated Food Allergy Sicherer and Sampson. J Allergy Clin Immunol. 2007; 120:491-503. Most Common Causes of IgE-Mediated Food Allergy From: FAO Technical Consultation, Rome, Italy (Nov., 1995) • • • • Cows’ milk Egg Crustacea Fish • • • • Peanut Soybean Tree nuts Wheat Food Allergies Prevalence Top Eight 90% Peanut Tree nuts Milk Egg Soy Fish Shellfish Wheat Others 10% Hundreds of others Commonly Allergenic Tree Nuts November 2006 FDA List • • • • • • • • • Almond Beech nut Brazil nut Butternut Cashew Chestnut Chinquapin Coconut Gingko nut • Hazelnut (filbert) • Hickory nut • Lichee nut (litchi, • • • • • • • lychee, leechee) Macadamia nut Pecan Pili nut Pine nut (pinyon nut) Pistachio Shea nut Walnut Commonly Allergenic Tree Nuts • • • • • Almond Cashew Brazil nut Pistachio Macadamia • • • • Walnut Pecan Hazelnut (filbert) Pine nut (pinyon, piñon) Rarely Allergenic Tree Nuts • Beech nut • Butternut • Chestnut • Chinquapin • Coconut • Gingko nut • Hickory nut • Lichee nut • Pili nut • Shea nut Other Foods That Cause Allergic Reactions • There are 160+ other foods that can cause allergic reactions Hefle et al. 1996. Critical Reviews in Food Science and Nutrition 36:S69-S89 Allergenic Foods on Common Allergen Lists in Other Countries • Sesame seed – Canada, EU, Australia/ New Zealand • Mustard – EU, Canada • Celery – EU • Molluscan shellfish – Canada, EU • Lupine – EU • Buckwheat – Japan, Korea Typical Symptoms of IgE-Mediated Reactions to Foods Gastrointestinal • nausea • vomiting • abdominal pain • diarrhea • Systemic • anaphylactic shock Cutaneous • urticaria • angioedema • atopic dermatitis • Respiratory • rhinitis • laryngeal edema • asthma Anaphylactic Shock • A generalized shock reaction • Can have multiple organ failure • Can have any of the other symptoms in addition to severe loss of blood pressure and cardiac arrhythmia • If not treated immediately, can be fatal Food-Induced Anaphylaxis is Not a Rare Occurrence Food allergy is the most common cause of anaphylaxis in U.S. emergency rooms (~30%) – Yearly estimates 50,000 anaphylactic reactions 2,000 hospitalizations 100 – 150 deaths Currently, no active treatment for food allergy other than strict avoidance of the offending food Allergic Reactions to Foods Can Occasionally be Fatal • Yunginger and co-workers, JAMA (1988) – 8 deaths from inadvertent ingestion of allergenic foods • adults and adolescents • Sampson and co-workers, NEJM (1992) – 12 deaths/near-deaths from ingestion of allergenic foods • children • Bock and co-workers, JACI (2001) – 32 deaths from inadvertent ingestion of allergenic foods • ages 2-33, with most victims adolescents or young adults CASE #1 Age, sex: 18,F Allergen: Peanut butter in restaurant chili Reaction: Onset in minutes; death in one hour Epinephrine: Subcutaneous, 20 min.; I.V. 40 min. Autopsy: Angioedema of lips, tongue, larynx, pulmonary hyperinflation CASE # 3 Age, sex: Allergen: 19, F Peanut-containing cookie; dormitory party Reaction: Onset in minutes; DOA within 1hr Epinephrine:Two 0.5 ml doses during resuscitation Autopsy: Focal pulmonary hyperaeration; terminal aspiration; no laryngeal edema CASE #7 Age, sex: 31, M Allergen: Fish-contaminated restaurant french fries Reaction: Immediate onset; death within 2 hours Epinephrine: Total 10 ampules during resuscitation Autopsy: Marked laryngeal edema Gingersnap Case Age, sex: 35, M Allergen: Peanut-contaminated gingersnap cookies Reaction: Onset 5 min. Epinephrine: Self-administered at onset and thirty min. later Symptoms: Bronchospasm, urticaria, abd. cramps, tachycardia, peripheral cyanosis Gingersnap Case (cont’d) Dose: 20 cookies Last exposure: 28 years previous Occupation: Allergist Analysis: 22,000 ppm peanut What Are the Causative Agents of Food Allergies? • Naturally-occurring proteins • Heat-resistant • Resistant to proteolysis • Resistant to extremes in pH • Usually major proteins of the food • Foods can have 1 or many allergens in them Treatment for True Food Allergies Specific Avoidance Diets Problems with Specific Avoidance Diets • Degree of selectivity • Knowledge of food composition • Exquisite sensitivity • Adequate nutrition • Restaurant meals • Confusing labeling terms Exquisite Sensitivity of Some Food-Allergic Individuals • Trace amounts of the offending food will trigger reactions How Much is Too Much? Milligram amounts! (ppm concentrations) Dose of Peanuts Causing Reactions in Highly Sensitized Subjects Lowest Eliciting Dose Taylor et al. Food Chem Tox., 2011 How to Manage a Food Allergy • Avoid offending food • Label education and diligent reading • Brand loyalty = safety Possible Preparation Errors/Oversights • Using same utensils/containers • Using same frying oil • Lack of restaurant labeling • Uninformed wait/cook staff • “Creative” recipe formulation • Tableside cooking Possible Processing Errors/Oversights • Inadequate cleaning of shared equipment • Use of re-work • Switching of ingredients • Formulation mistakes • Wrong labels/packages • Labeling terms Where Risks Occur • Research and Development • Engineering and System Design • Raw Materials/Suppliers/CoPackers/Purchasing • Labeling and Packaging Where Risks Occur • Production Scheduling/Changeovers • Rework • Sanitation • Human Error Food Allergies and Sensitivities: Conclusions • Affect a small percentage of the population • But, reactions can occasionally, be severe, even life-threatening Why the Increased Interest in Food Allergies? Food Industry – Increased consumer awareness – Potential impact of severe reactions – Increased number of product recalls – Increased attention by governmental regulatory agencies – Threshold dose is very low Food Allergies can be Deadly Serious Food Allergies An issue of growing concern An issue that is here to stay An issue that has increasing international aspects An issue that can be controlled Current Status of Food Allergen Issue • Recalls continue to occur in high numbers; 2nd leading cause in FDA Reportable Food Registry • Some companies have improved allergen control and decreased incidence of recalls • USDA has increased interest in food allergens and labeling • Recent label reviews • recent industry memo on high frequency of recalls • Labeling has improved but . . . .???