Spring 2013

Research Update

Spring2013-Research

Practical approach to nutrition and dietary intervention in pediatric food allergy

Highlights: Infants diagnosed with food allergy are at an increased risk for malnutrition. Nutrient dense foods are often restricted and nutrient requirements may increase (increased energy demands with tissue inflammation, decreased nutrient absorption, etc.). This article provides an overview of nutrition assessment in pediatric food allergy. Many practical tips are included, such as guidelines for incorporating baked egg or milk into the diet. When counselling infants on extremely restricted diets, other aspects of infant feeding are sometimes forgotten, such as the importance of progressing complimentary food textures. This article provides a good reminder. An excellent table compares allergen labelling in different countries, which is very helpful for clients that travel. For example, sesame must be labelled in Canada, but not in the the United States, where it may be hidden as natural flavoring or spice. Canadian clients with sesame allergy must be aware of this.

Application to Dietetic Practice: This article is written by one of the leading food allergy dietitians and her medical colleague. The practical nature makes it an excellent article for all pediatric dietitians. Dietitians experienced in pediatric allergy will likely encounter new information and insight.

Pub Med ID: 23384028

Nutrition assessment in celiac disease

Highlights: This article, written by two expert celiac dietitians, provides a useful overview of celiac medical nutrition therapy. The checklists for assessment, education topics, follow-up monitoring and sources of unintentional gluten ingestion make it a handy reference. Potential nutrition diagnoses are also provided. The clear and concise description of gluten-free label reading (US only) is excellent.

Application to Dietetic Practice: This article would be a handy reference for dietitians that occasionally see celiac disease clients. It would also be an excellent introduction to this topic for dietetic interns.

Pub Med ID: 23083994

Primary prevention of allergic disease through nutritional interventions

Background: Delaying the introduction of allergenic foods for the prevention of allergy is a controversial topic. In 2000, the American Academy of Pediatrics (AAP) recommended delaying highly allergenic foods for infants with a family history of allergy. However, allergy rates continued to rise. In 2008, the AAP issued a new report indicating there was no evidence to support delaying allergenic foods. Currently, results from intervention studies have not been published (there are only observation studies), so the evidence either way is weak.

Highlights: This article was written by the Adverse Food Committee of the American Academy of Allergy, Asthma and Immunology (AAAIA). The observational evidence is summarized.  The AAP position on not delaying allergic food is supported. The article furthers the discussion with more detailed directions on how complimentary foods should be introduced and situations when the family should be referred to an allergist for an individualized plan (e.g. an infant with severe atopic dermatitis or established food allergy).

Allergy prevention and dietary restriction during pregnancy/lactation/breast feeding and the selection of infant formula are also summarized.

Application to Dietetic Practice: This article should be read by all health care professionals that that advise the public on introduction of complementary foods.

Web Link (the AAAIA may also e-mail this article without charge)

Food-induced anaphylaxis: clinical highlights and knowledge gaps

Highlights: Very concise review of practical considerations in food anaphylaxis.

Application to Dietetic Practice: Good review for all dietitians in clinical practice.

Web Link

Resources Update

Spring2013-Resources

The Skinny on the Gluten-Free Diet and Your Weight (Article)

Description: Weight gain is a common problem after starting a gluten-free diet for celiac disease. This is beneficial if the client is malnourished from undiagnosed celiac disease, but in many cases the weight gain is unhealthy. Dietitians should caution newly diagnosed celiac clients about weight gain and suggest nutrient dense, lower calorie foods. Additionally, this is a great article to help clients understand that the gluten-free diet for weight loss is just a fad!!

Target Audience: General Public

Organization: Allergic Living Magazine

Website Link

Pasta Perfect

Description: An informative table comparing the nutrition profiles of gluten-free pastas. A great counselling reference.

Target Audience: General Public.

Organization: Shelly Case, RD and author of Gluten-Free Diet: A Comprehensive Resource Guide

Website Link

Potential opportunities for entrepreneurial dietitians

Description: After a recent lawsuit against an American university for not providing allergy safe meals, food service establishments (particularly other universities) may be looking for guidance.  The US Justice Department has determined that severe food allergies can be classified as disabilities under federal law (Americans with Disabilities Act of 1990). This will be particularly important for dormitories that require the students to eat most of their meals in the cafeteria. Dietitians could help these institutions by: 1) Educating staff on proper procedures and prevention of cross contamination 2) Creating allergy friendly menu choices 3) Speaking with individual students to determine needs (e.g. diagnosed celiac disease vs. gluten-free diet as a fad).

Website Link: There are many media articles on this recent lawsuit. Link to One Article

Your Clinical Questions

Spring2013-Q&A

I’m a pediatric dietitian, and families come to me with IgE test results from their family doctor. In many cases, there are several foods with moderate/high levels of IgE. If they are eating those foods and don’t have symptoms, should we restrict their diet?

No, the client would not need to restrict these foods. IgE antibodies mediate immediate hypersensitivity. The symptoms usually start within minutes, but can be delayed up to a few hours. The typical symptoms affect the skin (swelling, hives, itching), respiratory tract (wheezing, difficulty breathing) and the gastrointestinal tract (vomiting, diarrhea). Anaphylaxis is a severe reaction. Extremely high levels of food-specific IgE, indicates a high likelihood of an immediate reaction to that food. Unfortunately, the number that constitutes an extremely high level varies between allergens, has not been established for most allergens and varies with age. The clinical significance of a moderately high level of food specific IgE is questionable. In most cases, the patient can eat the food without reaction. Note: Many people still refer to RAST – which is the brand name of an outdated test. Food-specific serum IgE testing is the current name. Patients with suspected immediate food allergy should be assessed by a board certified allergist/clinical immunologist.
A good handout for patients is: Guidelines for the Diagnosis and Management of Food Allergy in the United States. Summary for Patients, Families, and Caregivers. Please read the paragraph under, Tests to identify foods causing your allergic reaction involving IgE (pg. 12). Table B on that page is a great summary.

When planning reintroduction challenges for foods that have been eliminated, do you start with foods based the IgE level, suspected symptoms, etc.?

If a food was eliminated because of high levels of serum IgE, the reintroduction should be done under medical supervision due to anaphylaxis risk. The challenge can be done at home if there is no history or suspicion of immediate allergy.  There is no “right way” to decide what foods to reintroduce first.  Foods that are strongly suspected as a trigger should be left until last. Clients usually appreciate starting with the foods that they miss the most.