Food Allergies and Intolerances and Their Importance to the Meat and Poultry Industry

1. 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 jbaumert2@unl.edu www.farrp.org

2. Food Allergies The food of one may be poison for another. Lucretius De Rerum Natura

3. Food Sensitivities (Individualistic Adverse Reactions to Foods) Food Allergy Food Intolerance

4. Food Intolerances • Anaphylactoid Reactions • Metabolic Food Disorders • Idiosyncratic Reactions

5. 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”

6. 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

7. Lactose Intolerance • Associated with deficiency of intestinal lactase (b-galactosidase) • 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

8. 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

9. Idiosyncratic Reaction • An adverse reaction to a food or food component among certain individuals occurring through unknown mechanisms

10. Some Examples of Idiosyncratic Reactions FoodSymptom • Chocolate Migraine headache • Tartrazine Asthma • Sulfiting agents Asthma • Food colors Hyperkinesis

11. Food Additives • Estimate 2,000 - 20,000 food additives • Preservatives, sweeteners, stabilizers, thickeners, colorings, flavorings, conditioners, antioxidants • Small number associated with adverse reactions

12. 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

13. Adverse Reactions to Ingested Sulfites • Asthmatic – proven • Nonasthmatic - controversial • Hives, pruritus, angioedema, hypotension, abdominal distress • Most not substantiated by double-blind oral challenge

14. 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

15. 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

16. Food Sensitivities (Individualistic Adverse Reactions to Foods) Food Allergy Food Intolerance

17. Food Allergy (Food Hypersensitivity) IgE-Mediated Cell-Mediated Celiac Disease Exercise-induced

18. 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

19. 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)

20. Food Allergy (Food Hypersensitivity) IgE-Mediated Cell-Mediated Celiac Disease Exercise-induced

21. IgE-Mediated Allergic Response: Mechanism Sensitization Phase

22. IgE-Mediated Allergic Response: Mechanism Elicitation Phase

23. 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

24. Prevalence • Between 3.5-4% of the U.S. population (or 10-12 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.

25. Prevalence of Specific Food Allergies in the U.S.* Crustacean shellfish - 1.9% Peanut - 0.6% Tree nut - 0.5% Fish - 0.4% *Based on FAAN telephone surveys

26. Prevalence of True Food Allergies Infants/young children - 4-8% Adults - 2-3%

27. 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)

28. Factors Involved in Development of IgE-Mediated Food Allergy Sicherer and Sampson. J Allergy Clin Immunol. 2007; 120:491-503.

29. Cows’ milk Egg Crustacea Fish Peanut Soybean Tree nuts Wheat Most Common Causes of IgE-Mediated Food AllergyFrom: FAO Technical Consultation, Rome, Italy (Nov., 1995)

30. Food Allergies Prevalence 90% Peanut Tree nuts Milk Egg Soy Fish Shellfish Wheat 10% Hundreds of others

31. 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 NutsNovember 2006 FDA List

32. Almond Cashew Brazil nut Pistachio Macadamia Walnut Pecan Hazelnut (filbert) Pine nut (pinyon, piñon) Commonly Allergenic Tree Nuts

33. Beech nut Butternut Chestnut Chinquapin Coconut Gingko nut Hickory nut Lichee nut Pili nut Shea nut Rarely Allergenic Tree Nuts

34. 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

35. 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

36. Gastrointestinal nausea vomiting abdominal pain diarrhea Systemic anaphylactic shock Cutaneous urticaria angioedema atopic dermatitis Respiratory rhinitis laryngeal edema asthma Typical Symptoms of IgE-Mediated Reactions to Foods

37. 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

38. 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

39. 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

40. 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 #1

41. CASE # 3 Age, sex: 19, F Allergen: 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

42. 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 CASE #7

43. Age, sex: Allergen: Reaction: Epinephrine: Symptoms: 35, M Peanut-contaminated gingersnap cookies Onset 5 min. Self-administered at onset and thirty min. later Bronchospasm, urticaria, abd. cramps, tachycardia, peripheral cyanosis Gingersnap Case

44. Dose: 20 cookies Last exposure: 28 years previous Occupation: Allergist Analysis: 22,000 ppm peanut Gingersnap Case (cont’d)

45. 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

46. Treatment for True Food Allergies Specific Avoidance Diets

47. Problems with Specific Avoidance Diets • Degree of selectivity • Knowledge of food composition • Exquisite sensitivity • Adequate nutrition • Restaurant meals • Confusing labeling terms

48. Exquisite Sensitivity of SomeFood-Allergic Individuals • Trace amounts of the offending food will trigger reactions

49. How Much is Too Much? Milligram amounts! (ppm concentrations)

50. Dose of Peanuts Causing Reactions in Highly Sensitized Subjects Lowest Eliciting Dose Taylor et al. Food ChemTox., 2011