J keller food allergies

I Can’t Eat That! Food Allergies in Corrections.

Ada County JailBoise, Idaho

Introduction

Case 1--38 year old man states that he is deathly allergic to onions and must have an onion free diet.

Case 2--19 year old man states that he is allergic to peanuts and has avoided them since childhood.

Case 3—29 year old female states she is allergic to milk. She requests a substitute for milk in her diet trays.

Goals

Understand IgE mediated allergic reactions

Know the incidence and risk of Food Allergy adverse events.

Know how to confirm food allergy by history and testing.

Adverse Food Reaction

Toxic Food Reaction

Food Intolerance Food Allergy

Non-IgE mediated ▪ (Celiac Disease)

IgE mediated

Toxic Food Reaction

Salmonella

Hangover

Food Intolerance

Food Allergy Non-IgE Mediated Most occur in

children < 3years old

Local reactions Poison Ivy reaction Food allergy

causing oral reactions

Celiac disease Not acute Takes time to

diagnose

IgE Allergy Mechanism

IgE sensitized.Attaches to Mast

CellAwaits next

encounter with the allergen.

IgE Allergic Reaction

Allergen attaches to IgEMast cell destabilizesReleases

HistamineProstaglandinsLeukotrienes

IgE Allergic Reaction

Urticaria Angioedema Respiratory Anaphylaxis

Urticaria and angioedema are by for the most common allergic reactions

Allergic reactions--Urticaria

Angioedema

Respiratory bronchospasm

Anaphylaxis

Cardiovascular symptoms Hypotension Vascular collapse

In conjunction with skin and respiratory symptoms

Other Manifestations of Allergic Reaction

Gastrointestinal Hypersensitivity Usually kids Vomiting, diarrhea, cramps Minutes to 2 hours after eating. In conjunction with hives and

angioedema. Exercise induced food allergy

IgE Allergic Reaction

Occurs in seconds to minutes.

Takes only a small amount of allergen to cause reaction.

Food Allergy Epidemiology Mostly a disease of

childhood

Allergies tend to abate with age

Food Allergy Epidemiology

CHILDREN

Cow’s MilkEggsWheatPeanuts, Tree

nuts

ADULTS

PeanutsTree nutsShellfish

Fish

Fruits and vegetables

Food Allergy Deaths

Food Allergy Deaths: 100/year

Penicillin allergic deaths: 400/year

Latex allergy anaphylaxis: 220/year

NSAID related deaths: 25,000/year

Food Allergy Deaths

Most deaths are teenagers/ young adults

>85% are due to peanuts and tree nuts

Virtually all had asthma. Virtually all had had a

previous severe reaction to the same food.

Virtually all did not receive epinephrine in a timely fashion.

Diagnosis—Detailed History

Right Age?Right Food?Emergency treatment?Allergist? Testing?EpiPen? Medic Alert?Restaurants? Shopping labels?

Diagnosis—Food Trial

Diagnosis--Testing

Skin Prick Test Easy to do. Inexpensive. Results in 15

minutes. Requires training

and supplies. Great for large

jails.

CapRAST

ImmunoCap Radioallergosorbent test

Measures IgE to specific antigens.

Accurate and predictable.

$45.00. Is this cost effective?

CapRAST

Positive defined as greater than 2.0kU/L

Sensitive but not specific.

CapRAST

CapRAST

CapRAST

Summary—Cap RAST

Sensitive, not specific. If negative, believe it. If positive, the patient still may not

be allergic. Expensive--$45.00. May be less expensive than the costs

of a special diet.

Incidence in Corrections

Of those referred to an allergist, <50% are actually allergic.

What about those coming into a jail or prison?

Food Allergy Incidence Ada Co. Jail

Ada County Jail is a 1200 bed facility located in Boise, Idaho.

Over a two year period, virtually all inmates who stated they had a food allergy were tested.

Ada County results

Allergen Number of Tests

Number Positive

Percent Positive

Peanuts 39 5 13%

Finfish (Tuna, Cod)

34 0 0

Cow’s Milk 12 0 0

Vegetables 10 0 0

Oatmeal, Wheat, Rice, Gluten

10 0 0

Shellfish 5 2 40%

Tree nuts 5 0 0

Fruits 4 0 0

Poultry 4 0 0

Beef 3 0 0

Egg 2 0 0

Introduction

Case 1--38 year old man states that he is deathly allergic to onions and must have an onion free diet.

Case 2--19 year old man states that he is allergic to peanuts and has avoided them since childhood.

Case 3—29 year old female states she is allergic to milk. She requests a substitute for milk in her diet trays.

Treatment Considerations Risk of

anaphylaxis. Food avoidance. Emergency

response.

Risk Assessment

HIGHER RISK

Teens to Early 20s

Previous severe reaction

Peanuts, Treenuts, shellfish

LOWER RISK

Older

Not the Big 3 foods

No documentation of previous severe reaction

Treatment—Food Avoidance

Special Diet

Kitchen Worker?

Cell or dorm where others eat the allergic food?

Treatment—Emergency Response

Epipens?

Emergency Response?

Food Allergy Prevention

Don’t serve “The Big 3 Foods”

Substitute Foods. Testing--skin prick

test and CapRAST.

Food Allergy Prevention #3 Work up protocol

Peanuts, fish CapRAST, Skin prick

test Tomatoes, onions,

etc. History test CapRAST, Skin Prick

Food Allergy Protocol

CATEGORY: MEDICAL AND NUTRITION   TOPIC: FOOD ALLERGIES   PURPOSE: TO GUIDE APPROPRIATE IDENTIFICATION AND TREATMENT OF PATIENTS WITH FOOD ALLERGIES     References. This protocol is based upon the following sources.

Adkinson: Middleton’s Allergy: Principles and Practice, 7th ed. Chapter 65—Adverse Reactions to Foods Food Allergy: Diagnosis and Management. Primary Care: Clinics in Office Practice. Vol. 35, issue 1 (March 2008) Rakel: Integrative Medicine, 2nd ed. Chapter 86—Adverse Food Reactions and the Elimination Diet

Introduction to food allergies in corrections In a correctional setting, the differentiation of true food allergies from food intolerance (especially simple food aversion) is essential. On the one

hand, jails do not want someone with a true food allergy to be served that food and suffer an allergic reaction. On the other hand, most inmates who claim to have a food allergy only have a food aversion and jails cannot feasibly grant a special diet to everyone like this.

Inmates who have no true allergy may use the claim of an allergy to avoid foods they do not like, in order to gain status among other inmates and to manipulate staff.

The goal of this endeavor is to accurately identify those individuals with a true food allergy and exclude those who do not have a true food allergy.

Definitions. Food Allergy refers to an immune-mediated allergic reaction to the glycoproteins in certain foods.

▪ Food allergies are most common in the very young.▪ Many patients with true food allergies loose the allergy over time.▪ Several studies indicate that most patients who report a true food allergy are found by diagnostic testing to not have that allergy in fact.▪ Most cases of true food allergies are to certain foods: nuts, shellfish, eggs.▪ An estimated 200 people die each year from acute allergic reactions.▪ Most of these deaths are due to peanut or tree nut allergies.

Food Intolerance refers to any non-allergic reaction to food. Food intolerance includes:▪ Food poisoning due to a toxin.▪ Side effects of substances found in some foods (example, headache caused by tyramine in wine or racing heart caused by caffeine).▪ Individuals lacking certain digestive enzymes, such as those with lactose intolerance and those needing pancreatic enzyme replacement.▪ Food aversion in which patients have a psychological revulsion for certain foods but experience no problems when they ingest that food unknowingly.

Adverse Food Reaction includes both food allergy and food intolerance. This term is used when it is not yet known if a patient has a true allergy or not.

Case One

38 year old man states that he is deathly allergic to onions and must have an onion free diet.

Right Age? Right Food?History--ER? Allergist? Testing?EpiPen? Medic Alert?Restaurants? Shopping labels?

Case Two

19 year old man states that he is allergic to peanuts and has avoided them since childhood.

Right Age? Right Food?History--ER? Allergist? Testing?EpiPen? Medic Alert?Restaurants? Shopping labels?

Case 3—Milk Allergy

An IgE milk allergy in an adult is rare.

The most common causes of milk “allergy” are:

Intolerance (eats ice cream and cheese)

Lactase deficiency (truly avoids dairy)

Treatment is Lactaid—on commissary.

jkeller@badgermedicine.com

Slides Outline Ada County Jail

Food Allergy Protocol

Questions