MEDICAL NUTRITION THERAPY IN MANAGEMENT OF FOOD ALLERGY

ACTA FAC MED NAISS
UDC 615.874:616.39
Professional article
ACTA FAC MED NAISS 2007; 24 (1): 45-50
Maja Nikolic1,2, Dragana Nikic1,2
Vladimir Mitrovic1,2
MEDICAL NUTRITION
THERAPY IN MANAGEMENT
1
OF FOOD ALLERGY
Faculty of Medicine
University of Nis
2Public Health Institute Nis
SUMMARY
When a food allergy diagnosis has been made, the avoidance of
allergenic food is the key towards successful management. The aim of this
review was to summarize the research and clinical evidence about medical
nutrition therapy in food allergy and to reduce the food allergic patient's risk of
developing malnutrition. Material and methods present a review of the
literature with clinical perspectives, but also include a commentary based on the
authors' clinical experience. Allergenic food exclusion claimed efficacy in more
than 90 percent of the analyzed studies. The food-allergic patient is less likely to
develop nutrient deficiencies when provided with appropriate food alternatives
and careful monitoring, while eliminating the food allergen(s) from the diet
management requires a multidisciplinary approach and follow- up. The main
management strategies for IgE-mediated food allergy are avoidance of
allergens, especially in children. Identifying individuals at risk may protect and
improve the patient's nutritional and overall health status. Every effort should
be made to ensure that the patients are fully educated in dietary management
measures and the dietician is the most qualified professional to address the food-
allergic patient's medical nutrition therapy needs.
Key words: food allergy, food hypersensitivity, medical nutrition
therapy, elimination diet
INTRODUCTION
changed significantly in recent years (3, 4). In gene-
ral, there are four approaches to the management of
During their lifetime, about one quarter of
food allergy: avoidance, education, pharmacothe-
the population will have some sort of adverse
rapy and immunotherapy.
reaction to food, especially during infancy and early
Total avoidance of a food allergen is the only
childhood. These adverse reactions are classified as
proven treatment for food allergy. Patients, their
food allergy, food intolerance, pharmacological
families and health care workers need guidelines and
reactions, food poisoning and toxic reactions. Food
suggestions for avoiding allergenic foods in meal
allergy is a condition caused by an IgE-mediated
planning and preparation and selecting nutritionally
reaction to a food substance that occurs in 1% to 2%
adequate replacement foods.
of the general population and in about 8% of children
(1,2).
AIMS
The evaluation and management of food
allergy have become more sophisticated and have
The aim of this review was to summarize the
Corresponding author. Tel. 018 251 26; fax 225 974; mob. 064 213 444 1 • E-mail: mani@junis.ni.ac.yu
45

---

Maja Nikolic, Dragana Nikic, Vladimir Mitrovic
research and clinical evidence about medical
the principles of human nutrition, the components of
nutrition therapy in food allergy and to reduce the
a healthy diet, and the complexities of dietary
food allergic patient's risk of developing
behavior. In treating food allergies, it is also
malnutrition.
necessary to be knowledgeable about food sources of
nutrients, botanical relationships, food composition,
MATERIAL AND METHODS
cooking methods, and alternative products and
where they are available. Dietary modifications
A review of the literature with clinical
typically involve changes in lifestyle and are usually
perspectives was performed, including a commenta-
not easily accomplished. Clinicians with counseling
ry based on the authors' clinical experience in the
skills as well as patience and sensitivity will be better
Nutritional Unit of a Public Health Institute in Nis.
able to assist individuals in complying with
Medline searches, using the terms food allergy, food
recommendations and achieving the desired results.
intolerance, diet, nutrition and related terms were
Enabling patients to accomplish dietary
done and many allergy and dietary textbooks were
change is a sequential process that requires and
used to identify articles and materials. Published
careful consideration of expected outcome versus
work was then selected for inclusion on the basis of
cost to the patient. A complete assessment, the
importance, pertinence, timeliness, accessibility, and
development and implementation of a realistic plan,
for further reading potential.
ongoing follow – up, and evaluation are essential to
improving outcome.
RESULTS AND DISCUSSION
A comprehensive nutrition assessment that
includes a careful evaluation of anthropometric,
Many foods have been claimed to cause
biochemical, clinical, dietary, and social parameters
allergy, but controlled studies show that a limited
should be incorporated into the management of
number of foods are responsible for the vast majority
patient with food allergy. These factors provide the
of cases (Table 1).
basis for nutrition recommendations and will
contribute to successful outcomes.
Table 1. The most common food allergens
Patient history is very important. Patients
should be asked to describe their perceptions about
Food
Cross reacting foods
allergy symptoms, causes, frequency and severity.
cows’ milk
goats’ milk, ewes’ milk
Details about season, location, and environmental
factors are also relevant. Additionally, it is necessary
hens’ eggs
eggs from other birds
to assess how seriously the individual's lifestyle is
affected by allergy.
fish, shellfish
mackerel, herring, plaice, crustaceans etc.
Patients should be weighted at each visit and
peanuts, tree nut
soy beans, green beans, green peas
any changes in weight evaluated (Table 2).
wheat
mostly unknown
Table 2. Checklist for Assessing Nutritional Status*
BMI < 20 or > 30 kg/m2
Also, some people are allergic to
Rapid weight loss (? 5% of body weight in 1 month)
strawberries and other berries, citrus fruits, tomatoes
and chocolate. Foods that rarely cause allergic
Major weight loss (? 10% in 6 months)
reaction include rice, lamb, gelatin, peaches, pears,
carrots, lettuce and apples.
Low serum albumin (< 3,5 g/dl)
The presence of food allergens can often
compromise an individual's nutritional status (10).
Low serum cholesterol (< 130 mg/dl)
Attention to adequate nutrition must be an essential
component of food allergy treatment.
Poor appetite
Appropriate nutrition management can:
1. Promote nutritional adequacy and
* Positive response to any of the above may indicate
contribute to improved health,
increased risk for compromised nutritional status.
2. Enhance outcome of food allergy treatment,
3. Improve management of comorbid
Many lifestyle factors can affect a patient's
conditions, and
ability and willingness to implement dietary
4. Foster a sense of well-being.
changes. A thorough evaluation and understanding
To provide appropriate nutrition care, health
of psychosocial factors provides vital data on which
care practitioners must have adequate knowledge of
46

---

Medical nutrition therapy in management of food allergy
to base individual nutrition recommendations (e.g.
dietitians because of the prevention of nutritional
economic status, occupation, educational back-
deficiencies and retardation of growth.
ground, living situation, stress level, cultural norms,
There are strong medical contraindications
alcohol or tobacco use etc.).
to using an elimination diet as treatment. These
A brief medical history review should
conditions could include (1) excessive weight loss,
include but not be limited to gastrointestinal
(2) undernutrition, and (3) anorexia nervosa.
concerns such as gastroesophageal reflux, irritable
Clinicians will be more likely to detect the existence
bowel syndrome, inflammatory bowel disease,
of these potentially serious problems by taking a
constipation, diarrhea, vomiting, or general
complete history and following the patients' progress
discomfort, hyperlipidemia, diabetes mellitus,
during the diagnostic phase.
anemia, eating disorders (anorexia nervosa and
Potentially, there are many obstacles to
bulimia nervosa).
changing dietary patterns. Sometimes, it is helpful to
The use of prescription and nonprescription
emphasize the types of food that can be consumed by
medications should also be reviewed. The use of any
the whole family - e.g., meat, potatoes, vegetables,
nutritional supplements should be determined,
and fruits. Financial concerns may be perceived. The
because supplements can contain substances with
presence of positive beliefs will foster behaviour
allergenic potential.
change. Clinicians who address barriers to behaviour
Knowledge of typical eating patterns will
change and foster a sense of self-efficacy will have
enable the clinician to evaluate nutrition adequacy
more success getting patients to follow dietary
and to more successfully adapt nutrition reco-
recommendations.
mmendations to the patient's lifestyle. Factors to
Strict elimination of the offending food
consider are: food preferences, including food
allergen(s) is the key management strategy (9,10).
avoided, number of meals eaten each day, typical
Elimination diets should be undertaken with caution,
meals, beverages, snacks, frequency of meals
especially if a significant number of foods or food
prepared at home and meals eaten out, special dietary
groups are avoided, because several reports have
considerations (e.g., vegetarian, low fat, kosher).
documented inadequate caloric intake and failure to
Dietary interventions should be carefully
thrive (5). Therefore, it is important to identify
planned so that patients with food allergy continue to
exactly which foods need to be eliminated and to
consume adequate amounts of energy and all
consider nutritional issues of a diet composed of the
essential nutrients. The Food Guide Pyramid and
allowed foods over the longterm.
other guidelines could be useful for both clinicians
Extensive instructions are imperative for
and patients. They could be useful to promote an
patients requiring long-term dietary modifications.
appropriate food selection from the key food
Guidelines must assure avoidance of allergens and
categories and thus optimize nutritional status (5,6).
promote overall health and well-being by following
Nutrient requirements for patients with food
basic nutritional principles. Also, it should include a
allergies are similar to the requirements for healthy
periodic review of symptoms and ongoing
individuals based on age. Particular attention should
assessment of nutritional status.
be paid to energy, protein, and fat intake in addition
The following checklist (Table 3) is useful
to particular vitamins, minerals, and trace elements
for planning elimination diets with patients.
for children with food allergies. Diet that omits
Suggested place to shop for such foods
sources of vital nutrients without adequate
include supermarkets and health food stores. In
substitutes can cause malnutrition and result in
Serbia, there is a lack of information about food
further health problems.
choices and the management of food allergies
Once a definite diagnosis of food allergy has
available through pamphlets, books and networks.
been made, a strict avoidance of the offending food is
Attention should be paid to the impact of any
of great importance. Depending on the severity of
allergy diet on comorbid conditions such as
symptoms and reactions, however, the benefits of
excessive weight loss, anorexia nervosa, obesity,
treating food allergy with dietary restrictions may be
diabetes, or gastrointestinal disease (12). It is
outweighed by the costs. Health workers who
important to avoid confusion and contradictory
recommend dietary changes should be sensitive to
recommendations. These situations call for highly
the difficulty of such an endeavor. Exacting dietary
skilled and specialized attention.
modifications can require profound lifestyle
Education about issues that arise in
changes, representing psychological, social and
undertaking dietary elimination, such as label
practical sacrifices to the patient (7,8).
reading, cross-contact, and selection of substitute
As is true of other chronic conditions, the
foods is crucial for successful elimination. It could
management of food allergy requires a multidiscipli-
be helpful to have the family bring in labels and keep
nary approach. Clinicians must coordinate care with
food/symptom diaries to help identify foods/
47

---

Maja Nikolic, Dragana Nikic, Vladimir Mitrovic
Table 3. Patient Guidelines for Maintaining a Nutritionally Balanced Elimination Diet
The foods to be avoided are:.................................................................................................
The foods that can be eaten are:............................................................................................
Concentrate first on the foods that can be eaten, rather than on those that must be avoided.
Include sources of the basic nutrients by eating according to the Food Pyramid.
Substitutes for favorite foods at breakfast, lunch, and dinner include ..................................
Substitutes for favorite beverages include:............................................................................
Concentrate on the basics and keep meals simple. Meats, poultry, fish, vegetables, potato,
rice, salads, and fruit provide excellent choices. Serve or request dressing and sauces on
the side.
Try new foods more variety.
Be open minded-forego traditions for breakfast, lunch, and dinner foods if desired.
Always read and evaluate food labels carefully.
Make or buy large quantities of appropriate foods. Eat leftovers and / or freeze extras.
Plan ahead for dining out and special occasions.
ingredients that are common in time to symptoms or
corn pasta would be a helpful substitution for a child
that may be identifiable as tolerated.
who frequently eats wheat pasta and is to be placed
on a trial of a wheat-free diet. Teaching parents how
Table 4. Alternative Foods Useful in an Elimination Diet
to replace the egg in the diet to provide an alternative
Milk substitutes: Beverages made from nuts, rice, soy
source of nutrients lost through the eliminationof egg
from the diet is one example (Table 5).
Starch substitutes:
Table 5. Egg allergy
Crackers made from rye, oat, rice;
Food to avoid: egg
Pasta made from corn, buckwheat, rice
Egg substitutes (equivalent to one egg):
Cooked grains: barley, millet, oat, buckwheat, rye, rice, potato
1/2 tsp baking powder + 1/2 tsp liquid + 1/2 tsp vinegar
Legumes
Bread made from rice, soy, millet
1 tsp yeast dissolved in 1/4 cup warm water
Peanut substitutes: nuts, nut butters, sesame seed
11/2 tsp water + 11/2 tsp oil+ 1 tsp baking powder
1 medium banana
Details such as the time of meal or snack,
brand name if commercially prepared, specific
ingredients if homemade, amount consumed, and
Supplementation with appropriate amounts
symptoms should be recorded. Such a list, along with
of calcium and vitamin D are important to
ingredient labels, may reveal hidden sources of the
individuals with milk allergy at any age. Another
food allergen or unknown sources of contamination.
issue of concern for patients with multiple food
Using alternative foods similar to what is recorded in
allergies is the distribution of carbohydrates, protein,
the diet diary can also significantly enhance
and fats in the diet. Modifications in food choices
adherence to the restricted diet. For example, rice or
should be made to ensure sufficient macronutrient
48

---

Medical nutrition therapy in management of food allergy
and energy intake (12). For example, a grain-allergic
also offer a nutritional safety net. Unfortunately,
child should be evaluated to ensure adequate intake
most supplements, even those marketed as milk-free,
of carbohydrates from alternative foods because
may be contaminated with milk and create problems
sufficient intake of carbohydrates is necessary to
for the milk-allergic individual. Use of fortified
prevent ketosis.
infant cereals is another way to supplement the diets
Detail information must be given to families
of children with multiple food allergies. Addition of
or patient about label reading (understanding non-
even a single serving of this cereal to the restricted
standard terms such as "casein" or "whey" that mean
diet of the food-allergic child can provide several of
cow milk), concerns about cross-contact of food
the needed nutrients.
allergens in commercial processing and in food
Prevention of food allergy in infants and
service such as restaurants, and the nutritional issues.
children includes breast-feeding, maternal dietary
Particular allergens may be hidden in the diet in
restrictions during breast-feeding, late introduction
unsuspected foods such as milk or egg proteins in
of solids and the use of hypoallergenic infant
bread products; milk orsoy protein in canned tuna, so
formula. It has been documented that the presence of
labels must be read carefully before serving food.
food allergens in breast milk is sufficient to induce
It is helpful to refer any person with food
reactions in infants (14). Milk and peanut protein
allergies to dieticians to provide family support,
were secreted into breast milk of lactating women
education, and counselling. Children tend to become
after maternal ingestion of these foods. In addition,
less allergenic as they grow older, but family
prophylactic restriction of some food allergens is
education is essential from the beginning.
suggestedfor infants at high risk for allergy.
Management requires a multidisciplinary approach
Introduction of solid foods before four
and follow-up (13).
months of life has been associated with a higher risk
To help identify and avoid offending foods:
of atopic dermatitis compared with delayed
· allergy – specific lists that describe foods
introduction. In addition, cereals can play an
to avoid;
important role in replenishing the infant's iron stores,
· list key words for ingredient identification,
which are usually depleted between four and six
and
months of age. Orange vegetables followed by fruits
· present acceptable substitutes that may be
(apple, pear, banana, plum, peach, and apricot) can
useful.
subsequently be introduced. Green vegetables
Success of elimination diets depends on
(spinach, peas and green beans) may be added
adherence and nutritional adequacy, and both can be
followed by grains (rice or oat, corn, white potato and
affected unless intelligent and creative choices are
wheat) and then meats. For infants at high risk of
made to allow diversity of taste and texture in
allergy, delaying the introduction of milk or soy until
addition to nutrition. Sometimes the removal of even
after one year of age; eggs until two years of age; and
a single food protein requires that a large number of
peanuts, tree nuts, fish, and shellfish until after three
products with diverse nutritional and social
years of age has been recommended.
advantage be excluded from the diet. For example, if
The physician plays a central role in
the allergy is to wheat, then all commercial breads,
identifying individuals with food allergy and for
cereals, baked goods, and pastas would be
continued monitoring of these patients. For
eliminated. Wheat is not only a main ingredient for a
comprehensive nutritional management, the
large number of products; it is also one of the
additional assistance of a dietician and an allergist in
common starches used in many processed foods. In
manycases could be useful:
this situation, the use of alternative grains (e.g., rice,
· For a definitive diagnosis (elimination
oat, potato) as flour in baked goods may provide a
diets, oral challenge);
solution. Use of commercial products with
· When there are multiple maternal dietary
alternative grains such as crackers, cakes, and pastas
restrictions duringbreastfeeding;
made of rice, corn or potato can also provide
· When food groups or multiple foods are
normalcy and convenience to the diet of the allergic
avoided(especially without a complete formula);
child on a wheat-restricted diet (Table 3, Table 4.)
· To determine appropriate substitutions of
The duration of the restricted diet also
allergenic foods.
becomes an important factor in management. If the
diet is modified for a short period for diagnostic
CONCLUSION
purposes, then a complete evaluation may not be
necessary. If the elimination diet is long-term, then a
Nutrition is an essential component in the
fullnutritional assessment is essential.
diagnosis and treatment of food allergy, so diet
A multivitamin and mineral supplement can
recommendations should be based on careful
49

---

Maja Nikolic, Dragana Nikic, Vladimir Mitrovic
assessment.
nutritional management of food allergy requires
The food-allergic patient is less likely to
education about dietary avoidance and consideration
develop nutrient deficiencies or malnutrition when
for nutritional deficiencies that may result.
provided with appropriate food alternatives and
The dietician is the most qualified
careful monitoring while eliminating the food
professional to address the food-allergic patient's
allergen(s), short or long-term, from the diet. The
medical nutrition therapy needs.
REFERENCES
1. Chapman JA, Bernstein IL, Lee RE, Oppenheimer J,
8. Fiocchi A, Bouygue GR, Martelli A, Terracciano L,
Nicklas RA, Portnoy JM. et al. Food allergy: a practice
Sarratud T. Dietary treatment of childhood atopic
parameter. Ann Allergy Asthma Immunol 2006; 96(3), Suppl 2:
eczema/dermatitis syndrome (AEDS). Allergy 2004; 59 Suppl
1-68.
78: 78-85.
2. Trevino RJ, Hamilton DS. Food allergy. Thieme, New
9. Mu?oz-L?pez F. Controversies in food allergy.
York, Stuttgart, 1997.
Allergol Immunopathol (Madr) 2006; 34: 43-5
3. Hourihane JO. Are the dangers of childhood food
10. Wahn U. Aspects of nutritional management of food
allergy exaggerated? BMJ 2006; 333(7566): 496-8.
allergy. Pediatr Allergy Immunol 2001; 12 Suppl 14: 75-7.
4. Baral VR, Hourihane JO. Food allergy in children.
11. Glavnik V, Kuhar M, Porenta-Besic V, Accetto M.
Postgrad Med J 2005; 81(961): 693-701.
Alergija za hrano.In:KrzisnikC, ed. Izbrana poglavlja iz
5. Moreno Villares JM, Oliveros Leal L, Torres Peral R,
pedijatrije.Ljubljana:Medicinska fakulteta Univerze u Ljubljani,
Luna Paredes C, Martinez-Gimeno A, Garcia-Hernandez G.
1994; 57-62.
[Growth in infants with cow's milk allergy][Article in Spanish]
12. Takwale A, Cox J, Selwyn E, Charles-Holmes S.
An Pediatr 2006; 64(3): 244-7.
Food allergy diets - a cautionary tale. Clin Exp Dermatol 2002;
6. Hon KL, Leung TF, Kam WY, Lam MC, Fok TF, Ng
27(8): 715-6.
PC. Dietary restriction and supplementation in children with
13. Sicherer SH. Food allergy. Lancet 2002; 360(9334):
atopic eczema. Clin Exp Dermatol 2006; 31(2): 187-91.
701–10.
7. Zivkovic R.: Dijetoterapija alergije i intolerancije na
14. Pastar Z, Lipozencic J. Adverse reactions to food and
hranu-Vegetarijanska dijeta. U Dijetoterapija. Naprijed, Zagreb,
clinical expressions of food allergy. Skinmed. 2006; 5(3): 119-
1994, 192-5.
25; quiz 126-7.
MEDICINSKA NUTRITIVNA TERAPIJA U
KONTROLI ALERGIJA IZAZVANIH HRANOM
Maja Nikoli? ,
1,2
Dragana Niki? ,
1,2
Vladimir Mitrovi?1,2
Me
1
dicinski fakultet, Univerzitet u Nišu, Zavod
2
za zaštitu zdravlja Niš
SAŽETAK
Nakon postavljanja dijagnoze alergije na neku hranu, izbegavanje alergogenih
namirnica je isklju?ivi pravac uspešne kontrole. Cilj ovog preglednog rada bio je da
objedini zaklju?ke epidemioloških i eksperimentalnih istraživanja, kao i klini?ka
tva
iskus
u vezi sa dijetoterapijom alergije na hranu, kako bi se smanjio rizik od pojave malnutricija
kod bolesnika sa alergijom na hranu. Materijali i metode predstavljaju pregled literature
sa klini?kim pristupom, a prikazana su i li?na iskustva autora. Efikasnost eliminacije
alergogenih sastojaka iz hrane potvr?ena je u 90% analiziranih studija. Kod bolesnika kod
kojih postoji alergija na hranu re?e su prisutni nutritivni deficiti ukoliko uzimaju
odgovaraju?e alternativne namirnice, a tokom eliminacije alergena z
i obroka važno je i
valjano pratiti nutritivno i zdravstveno stanje. Kontrola alergije na hranu podrazumeva
multidisciplinarni pristup. Osnovna strategija za kontrolu alergije na hranu je izbegavanje
alergena, posebno kod dece. Identifikacija osoba sa rizikom može uticati na uspeh
dijetoterapije. Treba u?initi što ve?e napore da se bolesnici edukuju u vezi sa pravilnim
sprovo?enjem dijete, a dijetolog je najkvalifikovanija osoba za sprovo?enje adekvatne
medicinske nutritivne terapije kod osoba sa nutritivnom alergijom.
Klju?ne re?i: alergija, hrana, dijeta, kontrola
50

---