FOOD ALLERGY

AND HYPERSENSITIVITY

INTRODUCTION

HISTORY OF FOOD ALLERGY

REVIEW OF BASIC IMMUNOLOGY OF ALLERGY

TYPES OF ADVERSE REACTIONS TO FOOD

DIAGNOSTIC FOR FOOD ALLERGY

TREATMENT OF FOOD ALLERGY

CONCLUSION
1

INTRODUCTION

Alergy :
antigens immune responses tissue
inflammation and organ dysfunction.

Food allergy :
food immune mediated symptoms.

US: 25-30%, in children (cow milk 2.5%,

peanuts 0.5-0.7%).

Internationally: 2.5% of infants, 1.4-1.8% of adults.

eggs 2%,

HISTORY OF FOOD ALLERGY

China (3000 B.c) :

cutaneous reactions caused by food

Hippocrates :
milk gastric distress and urticaria

Von Pirquet (1906) :

introduced the concept of allergy
skin tests detect food allergies
3

HISTORY OF FOOD ALLERGY

Rinkel (1934) :
developed the oral food challenge

Schloss, Rowe, and Coca :

delayed food sensitivity

Dr. Carleton Lee (1958) :

serial endpoint skin testing
singlefood antigens

responses

to

HISTORY OF FOOD ALLERGY

1963 :
provocation techniques
neutralization techniques
dietary management

treatment of food allergies

BASIC IMMUNOLOGY OF
ALLERGY ket di 2 RI, 3 RI,

Immune System

Made up : cells (in the circulation & the body

tissues) chemical substances interacting and
affecting foreign molecules.

An antigen
The nonspecific immune response :
reacts to broad categories of antigens
The specific immune response :
develops differently in every individual

Immune System

The specific immune response :

antigen activates specific lymphocytes

lymphocytes coordinate an immune response

eliminates the antigen

The immune response : humoral & cellular.

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Lymphocytes

Lymphocytes

20% of total leukocytes

T cells :

cell mediated immunity and cytotoxicity

regulate the immune system

B cells :

differentiates and secrete immunoglobulin

presence of specific surface ab receptors antigen

Natural killer cells : large granular lymphocytes

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Lymfoct

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Lymphocyt B NK Cell

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NK Cell

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Lymphocytes

T helper cells :
interacts and stimulates B cells

T suppressor cells :
antigen specific suppressor role
inhibit B-cell functions

T cytotoxic cells :
the destruction of infected or malignant cells
14

Immunoglobulins

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Immunoglobulins

the primary effectors of the humoral immune

response

basic structure :
the heavy chain :

determines the ability of an antibody to bind

to cells
confers immunoglobulin class

the light chains :

determine the specific antigen binding site

16

Immunoglobulins

Immunoglobulin E :

responsible for hypersensitivity reactions

bind to basophils and mast cells

Immunoglobulin M (10%) :

activates the classic complement pathway

assists IgA in defending external surfaces

Immunoglobulin A :

major immune barrier to antigen penetration

Immunoglobulin G (70-75 %) :

Protective, and forms blocking antibodies

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Antigen Processing Cells

Antigens enters the body phagocytes engulf and destroy

smaller fragments presenting these antigen fragments
to lymphocytes lymphocyte T or B cell is activated

B cells produces and secretes antibody specific to the

antigen, producing the sensitization.

T cell become a helper, suppressor, or cytotoxic cell.

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Antigen-Processing Cells

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Mediator Cells

Antigen antibody complexes mediator cells release

molecules :

histamine

chemotactic factors :
attract other leukocytes affect local tissues

leukotrienes :
control the development and duration of immune
reactions

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Mediator Cells

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Mediator Cells

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Complement

The complement system :

classic and alternative pathways.

Complement :
Amplification
and regulation of immune
inflammation.
Enhances uptake and removal of immune
complexes by phagocytosis.

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Complement

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Hypersensitivity Reaction

Allergy is a malfunction of the immune system that

involve any immune effector cells.

Hypersensitivity reactions immune responses acting

inappropriately cause inflammatory reactions and
tissue damage.

Hypersensitivity usually appears on subsequent contact.

Gell and Coombs classified into four classes of immune

reactions.

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Type I
Immediate Hypersensitivity

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Type I
Immediate Hypersensitivity

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Type I
Immediate Hypersensitivity

Prevalence approximately a 5%.

Each exposure to the offending food produces

an immediate symptom response.

Often severe and can be life threatening.

Can result : urticaria, rhinitis, angioedema, and

asthma, and anaphylaxis
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Type ll
Cytotoxic Reactions

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Type ll
Cytotoxic Reactions

Antibody binds antigen leads to :

phagocytosis
killer cell activity
complement mediated lysis

Clinical :
hemolytic anemia, transfusion reactions, and
rare cases of food reactions.
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Type III
Immune Complex Reactions

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Type III
Immune Complex Reactions

Formation of antigen antibody complexes with

subsequent tissue damage.

IgG + circulating antigens macromolecular

complexes precipitate in capillary beds,
binding and activating complement to produce
tissue inflammation.

Delayed in onset and prolonged in symptom

production.

Most common causing food hypersensitivity.

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Type IV
Delayed Type Hypersensitivity

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Type IV
Delayed Type Hypersensitivity

T-cell mediated .

Response occurring 24-48 hours after contact.

Sensitization the cell activated by a new

contact with the antigen T cells release a
variety of cytokines mobilize other
inflammatory cells produce a direct effect on
the target organ.
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Mixed Type Reactions

Mixtures of Gel and Coombs reaction types :

Circulating complexes.

Immunoglobulin (particularly IgE and IgG).

Complement activation.

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THEORY OF ACTION OF
NEUTRALIZATION TREATMENT

Jerne :
immune system negative feedback regulation.

This network turns on or turns off :

antibody formation and the activities of T
cells.

Low doses of antigen regulatory system is

shifted toward shutting off Ab 1 to the
original immunogen.
36

THEORY OF ACTION OF NEUTRALIZATION

TREATMENT

37

THEORY OF ACTION OF
NEUTRALIZATION TREATMENT

Direct effect of antigen on T cells :

Low dose antigen T-cell regulatory
mechanism favors the suppression of antibody
production.

The nonimmunologic mechanism involves

prostaglandin production : cytoprotective
effects of prostaglandin (Robert et al).

Low dose antigen desensitization

basophils for histamine release.

of

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THEORY OF ACTION OF
NEUTRALIZATION TREATMENT

Low dose antigen therapy :

Downregulating both B cell

production and T-cell function.

Increasing intracellular
monophosphate levels.

Decreasing cell metabolism.

cyclic

antibody

adenosine

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TYPES OF ADVERSE
REACTIONS TO FOODS

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Food Intolerance

Nonimmunologic Reactions.

Anaphylactoid reactions :

Due to the nonimmune release of chemical mediators

contained in foods .

Idiosyncratic reactions :

Due to abnormal responses genetically predisposed

patients.

Asthmatic patient reacting to salicylates.

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Food Intolerance

Digestive enzyme deficiencies :

Lactase deficiency gastrointestinal symptoms.

Toxic reactions :
Food components or additives and toxins released by
microbes in food.

Pharmacologic reactions :
Chemicals in foods produce drug like effects.

42

Food Hypersensitivity

Penetration of antigen crossing the gut

triggering the formation of specific antibodies .

Factors influencing food allergies :

The permeability of the gut mucosa.
Crossreactivity
between a food and
inhalant allergen.

an

Clinically : fixed food allergy and cyclic types.

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ADVERSE REACTIONS TO FOODS

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Fixed Food Allergy

IgE mediated responses.

Immediate
allergen.

Sensitivity to the food usually persists for

years.

Symptom doesnt depend on the quantity of

food eaten.

Present in various ways.

reaction

after contact with

the

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Atopic Dermatitis

37% of children with moderate to severe atopic

dermatitis have type I food allergy.

Most common : cow's milk, fish, and eggs .

Mechanism
unrelated
to
IgE
mediated
histamine release also can trigger mast cell
degranulation after the ingestion : alcohol,
spicy foods, or additives.
46

Asthma

Inhalation of airborne food antigens, steam

from cooking food or also can be triggered by
ingestion of the offending food

Symptoms may include rhinoconjunctivitis,

urticaria, laryngeal edema, and shock.

Foods : eggs, flour, cocoa, peanut, soy, garlic,

tea, fish.
47

Urticaria

Urticaria is a wheal and flare cutaneous reaction.

Contact urticaria :
cutaneous contact with prolonged handling of raw food,
and occur around the mouth in children.

Angioedema (45% of the cases ):

nonpruritic swelling, sometimes painful,
suddenly and no more than 3 days.

developing

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Oral Allergy Syndrome

Local IgE mediated mast cell activation

swelling of the lips, tingling of the tongue and
throat, and blistering of the oral mucosa.

Associated with the ingestion of food crossreact

with their specific allergic inhalant (40% ).

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50

Oral Allergy Syndrome

Major cross-reactions include:

Birch with apple, carrot, celery, hazelnut, kiwi, peach,

pear, and potato.

Dust mites with shrimp and snail.

Grass with kiwi, melon, tomato, watermelon, wheat,

and other grains.

Latex with avocado, banana, chestnut, kiwi, and rose

family fruits such as cherry and peach.
51

The Gastrointestinal Syndrome

Accompanied allergic manifestations in other

target organs.

Symptoms :
abdominal cramps, nausea,
watery diarrhea, hypotension.

vomiting,

and

52

Anaphylaxis

Death : respiratory or cardiac failure.

Clinicaly :

Early stages : urticaria, angioedema, bronchospasm,

laryngeal edema.

Gastrointestinal tract : nausea, vomiting, diarrhea.

Cardiovascular : hypotension, dysrhythmia, collapse.

Factors associated severe reaction :

Asthma.

History of previous severe reactions.

Failure to initiate therapy expeditiously.

53

Cyclic Food Allergy

IgG mediated, type III immune complex disease (6O%

to 80% of food sensitivity).

Dose and frequency related.

antigens immune complexes

frequency sensitivity

More often IgG forms immune complex

formation.

Omission of the food

antibody levels and
immune complexes symptoms.
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Stage of Cyclic Food Allergy

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DIAGNOSTIC
FOR FOOD ALLERGY

56

HISTORY

Diagnosis depends on a patient's history.

Actual diet habits, time of ingestion.

Time of any symptoms observed.

Record any improvement of symptoms.

Analyzes :
production.

Most people tend to be habit eaters, the hidden foods

are an universal problem.

frequently

eaten

foods

and

symptom

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HISTORY

Problem : hidden food, allergic crossreactions

between closely related foods .

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Signs and Symptoms

Depend on : fixed or cyclic.

Fixed allergy :

Obvious signs and symptoms.

Symptoms are secondary to release of histamine,

preformed mediators, and the late phase reaction.

Patients can not identify what food is causing :

mixture of foods

chronic allergy conditions

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Signs and Symptoms

Cyclic food allergy :

More complex and difficult to recognize.
Secondary
to the slow accumulation of
immune complexes in the capillary beds of
target organs.
Symptoms depends on frequency and the
amount of antigen consumed.
There are many common symptoms and
signs .
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Neurologic Symptoms

Neurologic symptoms :
headaches
learning disabilities
forgetfulness
short attention
insomnia
even seizures can be food triggered

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Ophthalmologic Symptoms

Mild symptoms :
pruritus, stinging, (conjunctival, eyelid,
periorbital, lid) edema with itching, scaling,
and erythema.

Severe symptoms :
tearing, burning, discharge, photophobia,
rough tarsal mucosa, blurred vision, the
cornea should not be inflamed, or eroded.

62

Otologic Symptoms

External : chronic otitis externa, narrowed ear

canals, red auricles, scaling.

Middle ear : pressure sensation, lancinating

pains, otitis media with effusion, persistent
otorrhea.

Inner ear : dizziness, disequilibrium, tinnitus,

and dull ear pain.

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Nasal Symptoms

Nasal obstruction
Voice change, Snoring
Sleep disturbance
Edema of the turbinates
Rhinorrhea
Thick postnasal discharge
Crusting
Pruritus, Sneezing
Decreased olfaction
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Oral Symptoms

Pruritus oral, perioral, and palatal.

Dry mouth.

Halitosis.

Geographic tongue.

Angioedema of the lips and oral mucosa.

65

Pharyngeal and Laryngeal

Symptoms

chronic sore throat

pharyngitis
chronic throat clearing
perception of a lump in throat
enlarged
lateral
pharyngeal
bands
and
posterior pharyngeal lymphoid islands (due to
postnasal drip)
laryngeal edema with intermittent hoarseness

66

Pulmonary Symptoms

chronic cough

shortness of breath

chest tightness

chest pain with breathing

Wheezing

thick-tenacious-colorless sputum
67

Gastrointestinal Symptoms

intermittent abdominal pain

vomiting
diarrhea
abdominal distention
constipation
pruritus ani
perirectal inflammation ("burned butt")
acute cramps
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Genitourinary Symptoms

Enuresis

Pruritic

Vaginitis

Food or inhalant induced allergic nephrotic

syndrome
69

Musculoskeletal Symptoms

Arthralgias

Myalgias

Stiffness

Erythema or edema over joints

70

The Skin Symptoms

Atopic dermatitis and eczema.

Urticaria.

Angioedema.

The Id reaction.

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DIAGNOSTIC TECHNIQUES
FIXED FOOD ALLERGY

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Specific Immunoglobulin E Testing

History : serious reaction, significant asthma.

Low sensitivity results :

Commonly are seen without history food
allergic.

High sensitivity results :

Significant symptoms will be produced if
that food is ingested.
Those foods should be permanently avoided.
73

Basophil Histamine Release

Methods :
radioimmunoassay, fluorometry, high pressure
liquid
chromatography,
glass
microfiber
adsorption of histamine.

Histamine release results correlate well with

results from skin tests, provocation tests, and
specific IgE tests .

Advantage : allows detection of both allergic

and anaphylactoid reactions.
74

Prick Tests

Lewis and Grant (1926), and Pepys (1970s).

Specific, easily, and infrequently cause systemic allergic

reactions.

Variations : precisely reproducing the depth of

penetration, amount of force used, and the amount of
skin lifting.

Correlations : 85% to 90% (in vivo tests), 81% to 89%

(intradermal skin endpoint titration tests).

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Modified Prick Tests

Modified :
multiple and longer tips introduce greater quantities
of antigen and increase sensitivity similar to
intradermal tests .

Multi Test I : test eight antigens simultaneously.

False positive reactions

tests are placed closely
together (separated by approximately 2 cm).

76

Patch Tests

Detect delayed allergic reactions.

Allergens are applied to the intact skin

occlusive dressing allowed to react.

Variations of patch testing :

skin preparation technique
antigen dose
method of antigen solubilization
the type of occlusion
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Patch Tests

Advantages : nonpainful and rarely causing

systemic reactions.

Sensitivity : 61-77%, specificity : 71%-81%.

Difficulty in differentiating irritative reactions

from true allergic responses.

Patch tests less sensitive than prick tests.

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DIAGNOSTIC TECHNIQUES
CYCLIC FOOD ALLERGY

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In Vitro Food Tests

Cytotoxic test .

IgG and IgG4 in vitro assays.

The antigen leukocyte antibody test.

The ELISA activated cell test.

Basophil histamine release tests.

Positive results should be corroborated by oral

food challenge.
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Oral Challenge Test

The oral challenge test :

Dietary analysis.

Elimination of a specific food for 4 to 5 days.

Ingestion of that food in large amounts.

Difficulty : only one food can be tested at a time.

Easier to perform and more closely mimics normal food

the open, unblinded oral challenge.

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Elimination

Eliminate the food to be tested as completely as

possible.

Patient instructions :

Food should be eaten every day for 2 weeks

Eliminated the food for 4 days

Breakfast with safety food

Plan the test 5 hours later

Avoid food, liquid, medicine and smoking before test

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Challange

Baseline symptoms and pulse are recorded.

Prepare the foods.

Fed the pure food within a 5-minute.

The patient is observed for a minimum of 2 hours.

Subjective and objective symptoms are recorded.

Alka Seltzer Gold, unflavored milk of magnesia or 2-3 g of

vitamin C may relieve provoked symptoms.

Symptoms are weak the test repeated.

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Rechallenge

Initial avoidance period of 2 or more months

rechallenge produce no symptoms
rotated food.

Positive food should be avoided for several

months another challenge no reaction, or
until 2 years of avoidance.

Positif after 2 years fixed food allergen

lifelong avoidance.
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IPDFT

Accurately diagnosis : IPDFT.

using the sequential injection of several different

dilutions of each food allergen

similar in principle to skin endpoint titration

Breneman and Kuwabara et al :

food antigens are applied to the dermis immune
complexes and complement mast cell degranulation.

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Performing the IPDFT

1 mL antigen + 4 ml phenolated saline (# 1)

#2 to #6.

Checking skin reactivity with a (+) and (-) control.

Applying 0.05-mL wheals of a antigen and a glycerin.

Observed for up to 10 minutes.

Negative : no size difference and no symptoms.

Positive : antigen wheal > 2 mm or more, with or

without symptoms.

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Performing the IPDFT

Continued with weaker antigen no growth.

The dilution at negative response = the end point of

titration.

If no wheal growth or symptoms occur with the #1

dilution : nonallergenic.

Repeating the injection of that dilution once or twice

relieves the symptoms : endpoint is called a multiple.

87

Performing the IPDFT

Differences between IPDFT and SET :

Food testing injects five times (0.05 vs. 0.01 mL).

Larger wheals (7 vs. 4 mm).

Food testing uses much stronger initial antigen

solutions.

Food testing : the endpoint is the first nonreactive

wheal.

Inhalant testing : the endpoint is the first reactive

wheal that initiates progressive whealing.
88

Performing the IPDFT

The IPDFT end point = the therapeutic neutralizing dose.

The neutralizing dose :

Triggers the prostaglandin protective mechanism.

Stop the production of IgG.

Successful neutralization :

Stops the allergic reaction.

Makes the positive wheal disappear.

Reverses any symptoms produced.

89

Food Skin Testing Safety Guidelines

Never test : food fixed allergy.

Test only for foods on a regular basis.

Carefully for a history of any past serious

allergic reaction.

All foods to be tested must have been eaten

within 24 hours of testing.

Consider IgE in vitro testing.

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TREATMENT OF FOOD ALLERGY

91

TREATMENT OF FOOD ALLERGY

Medical Care.

Education.

Consultations.

Elimination of food allergen.

Neutralization.

Avoid high-risk situations.

92

Education

Education is of paramount importance.

Resource information by contacting the

Food Allergy and Anaphylaxis Network

(toll-free
phone number is 800-929-4040)
International Food Information Council
(phone
number is 202-296-6540 and email address is
foodinfo@ific.org).

Remember that appropriate restriction of the relevant

food allergen(s) is the only current effective therapy.

93

Consultations

Consultation with a nutritionist.

The restriction diet can be reviewed and
appropriate
substitutions
can
be
recommended.
Dietary deficiencies can be anticipated and
prevented.

Consultation with a gastroenterologist.

Useful in the workup of selected patients.

94

Medication

Medication : accidental may occur.

For patients with mild reaction :

treatment may be limited to an oral antihistamine.

For patient with significant systemic symptoms :

the treatment of choice is epinephrine injection.

Medical therapy of food allergen induced allergic

reactions :
the use of antianaphylactic agents, antihistamines,
bronchodilators, and corticosteroids is suggested.
95

Diet

The many variations of rotary diets used today

all share essential features.

Many allergists : strict exclusion could possibly

have any benefits.

96

Elimination, Reintroduction,
and Rotation of Foods

Rechallenge is first attempted after 2 or 3 months.

Tolerance : rechallenge produces no symptoms (decline

in sensitized cells and antibody levels below the
threshold levels for mediator release).

Once tolerance a rotation diet (every 4 days).

Every 3 days will cause resensitization.

Several meals on the same day cause resensitization.

2 years of omission still produces symptoms fixed

food allergy.
97

The One-Food-per-Meal
Rotation Diet

For diagnosis of patients :

with serious symptoms

a simple maintenance rotation diet has failed

Suspect lists :

skin test, diet diary, level IgE in vitro test

Safe list :

all foods that are acceptable, eat < weekly

uncertain foods, eat < daily, but > weekly

98

COMBINING
DIETS AND NEUTRALIZATION

The best treatment is elimination of the food :

Fixed food allergy : eliminated indefinitely.

Cyclic food allergy : eliminated for several months

reintroduction (a rotary, diversified diet).

Neutralization immunotherapy + the best possible diet :

Allergies to ubiquitous foods.

Cannot eliminate those foods from the diet.

Difficult to rotate in the diet or to eliminate.

99

Neutralization
Dosing Schedules

Trevino :
every day for 2 weeks twice a week for 2 months
once a week for 6 to 7 months.

King :
injections twice weekly for 1 month
month every other week.

weekly for 1

Gordon :
twice weekly injections for as long as required.

100

Neutralization
Dosing Schedules

Treatment doses are not escalated.

Relapse possible endpoint shifts.

Food injection able to stop :

Low dose tolerance has been achieved.
Better dietary habits.
Clean up their environment.
Escalate to effective inhalant therapy.

101

Sublingual Neutralization
Food injection therapy is begun + dropper vial
(the same food antigens, neutralizing dose strength)

produce prostaglandins

prevent symptoms
(until the injection therapy becomes fully effective)

Schedules of neutralization injection and sublingual

therapy :
different combinations and comparative efficacy studies
have not been performed.
102

CONCLUSION

True food allergies are those reactions that occur

because of the activity of the immune system when
exposed to sensitizing foods.

Clinically, true food allergies occur in two very different

types: immediate, fixed reactions, and delayed, cyclic
reactions.

Fixed food allergies develop rapidly after food exposure,

and therefore usually are easy to diagnose.

103

CONCLUSION

Conversely, cyclic food allergies often develop slowly and

vary with both the quantity and frequency with which
allergenic foods' are eaten.

It is important to learn about cyclic food allergies

because they represent most of the clinically observed
food allergies, and are a very important cause of
treatable chronic allergy symptoms.

Understanding the clinical behavior of cyclic food

allergies allows the physician and patient to cooperate
for both diagnosis and successful intervention..

104

THANK YOU

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Complement

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115

Masked Sensitization

The sensitized food is eaten frequently

immune complex disease chronic symptoms.

Masking phenomenon : small and frequent

exposures to the offending food brief
symptom relief.

Dependence on this masking action for

continued well being often results in food
addiction.

116

Omission

Food is omitted (4-5 days) antigen is cleared

from the gut and the circulation.

High level of specific anti food IgG is still

circulating.

If no antigenic food is consumed :

Antibody levels remain high.
Without symptoms.
117

Hyperacute Sensitization

Circulating antibody :
antigenic food is consumed

immune complex formation

provocation of symptoms

This stage lasts 4 to 12 days

118

Active Sensitization

Antigenic food is consumed symptoms are

produced (less severe).

For greatest sensitivity :

oral food challenges should be performed
during the 5-12 day after food omission.

119

Latent Sensitization

No antigen stimulation
The antibody levels decrease.
Continued antigen elimination.

An antigenic food ingestion mild symptoms

or no symptoms (unless several exposures
occur).

120

Tolerance to Foods

After 4-5
avoidance.

months

of

continuous

antibody production and food ingestion no

produces symptoms.

Rotated foods avoid increased antibody

formation.

If tolerance cannot be
avoidance is required.

attained,

antigen

life

long
121

Sensitization

Ingests the food frequently antigen

exposure renewed antibody production,
immune complex formation, symptoms.

Symptoms of resensitization are mild

patients may not notice they may complete
the circle and again enter the stage of masked
sensitization.

The resensitization proces take 1-2 week to

complete.
122

Skin Testing
Multiple Foods Simultaneously

Developed by Walter Ward and William King (1980).

Normally, three to six are tested, depending on :

Clinical assessment of the patient's.

Degree of sensitivity.

The experience level of the tester.

Novice testers : begins with #3.

Experienced testers : begin with # 1 dilutions.

Sensitive patients : begin with #5

123

Elimination, Reintroduction,
and Rotation of Foods

Treatment of cyclic food allergy :

elimination (5 to 6 months) the tolerance
stage reintroduced (once or twice per week).

Aim :
preventing an increased production of specific
IgG.

124

Elimination, Reintroduction,
and Rotation of Foods

The way to start a rotary diet :

single food eliminations, oligoallergenic diet, and fasting.

Singe food eliminations :

simple to do

work best

eliminated for 4 days

requires knowledge of what ingredients are in foods

often used in small children

125

Elimination, Reintroduction,
and Rotation of Foods

Oligoallergenic diets :

focus on permitted foods,

do not demand so much attention to detail

eliminate most common allergens

Supervised fasting :

safely with most healthy patients ,

patients must be very cooperative

complete physical, laboratory examination, internal

medicine consultation before fasting

only pure water and mild laxatives is allowed until

126

Essential Features
of the Maintenance Rotary Diet

Patients must permanently avoid all fixed food allergens.

The list of suspected cyclic allergy foods is drawn from

IPDFT-positive foods, foods the patient craves, the diet
diary.

Patients must avoid all challenge positive foods for at

least 2 or 3 months before rechallenge.

How often each reintroduced food can be safely eaten

varies.

127

Essential Features
of the Maintenance Rotary Diet

Patients must avoid all forms of sensitizing foods until

testing proves certain forms to be tolerated.

Patients must avoid all amounts of sensitizing foods until

testing.

All other (nonsuspect) foods should be rotated on a 4day

schedule.

Patients should eat a normal serving of a food only once

on a permitted day.

Stress the importance of not eating too many foods on

any one day.
128

Essential Features
of the Maintenance Rotary Diet

Patients should
obtainable.

use

the

purest

foods

and

water

Patients should keep a continuing diary of foods eaten

and symptoms present.

Patients should keep written instructions for the diet,

including information on food families, hidden sources of
sensitive foods, and how to construct an allowed food
chart for home use.

129

Essential Features
of the Maintenance Rotary Diet

Check diet for adequate nutrition.

Do not allow deviations from the prescribed diet unless

the patient discusses them with you first.

Review progress at regular intervals.

Stress the fact that success is up to the patient: it is his

or her responsibility.

Also stress that no one is perfect, that patients should

be satisfied with their honest efforts and whatever
symptom improvement they can achieve.
130

The One-Food-per-Meal
Rotation Diet

Oligoallergenic diet or fasting possible cyclic food

allergy is challenged (only food at one meal in a day).

A very strict 4-day rotation diet :

safe list of foods (+) food challenge + mild

laxative

If (+) food is eliminated.

If (-) that food is added to the list of safe foods.

It is important to remember that omission for too long

can produce a false negative challenge.

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