Medications for Allergy

Monosodium glutamate, a flavor enhancer common in Chinese cooking, is used increasingly to flavor Western foods. In addition, some foods, such as tomato, mushrooms, and cheese, contain natural glutamates that resemble Monosodium glutamate. A glutamate is a derivative of the amino acid called glutamic acid that is an essential part of proteins.

Persons sensitive to Monosodium glutamate report a variety of symptoms known as the “Chinese Restaurant Syndrome” or “Kwok’s Syndrome.” Symptoms may include facial flushing, pain in the face and the back of the neck, headache, tingling and burning sensations, blurred vision, nausea and vomiting, increased heartbeat, chills, and shaking. Several incidents of severe asthma have been attributed to the ingestion of Monosodium glutamate; depression, irritability, and other mood changes have also been reported.

Experts are widely divided on the subject of Monosodium glutamate sensitivity. A recent review stated that results of a number of research studies “led to the conclusion that ‘Chinese Restaurant Syndrome’ is an anecdote applied to a variety of postprandial [occurring after a meal] illnesses: rigorous and realistic scientific evidence linking the syndrome to Monosodium glutamate could not be found.” On the other hand, some clinicians have estimated that the prevalence of Chinese Restaurant Syndrome may be as high as 1.8% of the adult population.

This chapter will provide you with information on what you may experience if you are sensitive to glutamates. It discusses how glutamates may cause your symptoms, and how to reduce your intake of glutamates without causing any nutritional deficiencies in your diet.

How Monosodium glutamate

Causes Symptoms

Monosodium glutamate is the sodium salt of glutamic acid, an amino acid. Glutamate is the active ingredient in the compound.

One theory to explain sensitivity to Monosodium glutamate links its action to abnormally high levels of acetylcholine, a neurotransmitter that acts on the brain and central nervous system. Because glutamate acts as a building block in the synthesis of acetylcholine, as well as other physiological chemicals, the symptoms of Monosodium glutamate sensitivity may be caused by excessive levels of neurotransmitters that develop in a short period of time. Toxic levels of acetylcholine may explain the symptoms of the Chinese Restaurant Syndrome.

The usual source of glutamate is food proteins, where it is combined with other amino acids. Before glutamate is free to be absorbed by the body, the pep-tide bonds in these proteins must be broken by enzymes in the process of digestion. Because this process is gradual, it controls the level of free glutamate in the body. According to the theory of “neurotransmitter toxicity” when Monosodium glutamate is eaten, glutamate enters the bloodstream rapidly because no peptide linkages need to be broken. Clinical studies have shown that an Monosodium glutamate dose of 0.1 gram per kilogram of body weight can induce plasma glutamate levels to rise to 15 times the normal concentration in about one hour. However, a relationship between plasma glutamate levels and symptoms has not been demonstrated in well-conducted research trials.

Some practitioners have noticed a deficiency of vitamin B6 (pyridoxine) in a number of Monosodium glutamate-sensitive persons. This deficiency could reduce the breakdown of glutamate in the liver, thus prolonging high plasma glutamate levels and causing symptoms to worsen.

Symptoms Possibly Caused by Monosodium glutamate

The following symptoms are reported to be caused by Monosodium glutamate:

Symptoms of Chinese Restaurant Syndrome are reported to usually occur within 30 minutes of eating a meal high in Monosodium glutamate. Symptoms of asthma, however, have been reported to occur 1 to 2 hours after Monosodium glutamate ingestion and even as long as 12 hours later.

Management of Monosodium Glutamate Sensitivity

A “safe level” of Monosodium glutamate in foods cannot be set because a number of different factors contribute to plasma levels of glutamate, only one of which is the Monosodium glutamate added to food. Glutamate is a natural component of the body, where it plays an essential role in metabolism. Enzymes called transaminases in the liver allow glutamate to interact in a variety of reactions, and free glutamate is also found in muscle, brain, kidneys, and other organs. A person who weighs 70 kilograms has the equivalent of about 12 grams of Monosodium glutamate in his or her body. Whether or not any particular plasma level can be considered “safe” is not known.

Milk contains natural free glutamate. The daily intake of a 3 kilogram infant obtained from 480 grams of mother’s milk is 3.75 grams (1.25 g/kg body weight).

The Joint FAO/WHO Expert Committee on Food Additives has evaluated Monosodium glutamate and has judged that no restriction is necessary for the use of Monosodium glutamate in food. This means that Monosodium glutamate can be added to any prepared food to the level that the manufacturer considers optimum for enhancing the flavor of its product.

Because Monosodium glutamate is a food additive that appears on the Generally Recognized as Safe (GRAS) list, a food manufacturer is not required by law to include Monosodium glutamate in a list of ingredients on product labels. Listing Monosodium glutamate as an ingredient is voluntary on the part of the manufacturer.

Monosodium glutamate-sensitive persons should restrict their intake of Monosodium glutamate as much as possible. Because alcohol seems to increase the rate of absorption of many foods as well as Monosodium glutamate, drinking alcoholic beverages while eating Monosodium glutamate-containing foods probably increases both the severity and rate of onset of symptoms. In addition, eating foods containing Monosodium glutamate on an empty stomach seems to increase the adverse effects of Monosodium glutamate.

Sources of Monosodium glutamate

The following flavorings contain Monosodium glutamate and may appear on food labels:

Many prepared foods contain Monosodium glutamate or one of the above flavorings. Foods containing these additives include

Canned meats

Prepared dinners and side dishes

Canned soups

Dry soup mixes

Gravy and seasoning mixes

Cookies and crackers

Cured meats

Smoked meats and sausages

Diet foods

Freeze-dried foods

Frozen foods

Potato chips

Prepared snacks

Prepared salads, salad dressings, and mayonnaise

Croutons

Bottled and canned sauces

Spices and seasonings

Glutamate is also present in monopotassium glutamate, monoammonium glutamate, calcium glutamate, and other salts of glutamic acid. Some Monosodium glutamate-sensitive persons may react to these salts also. Look for these terms on food labels.

Restaurants, Cafeterias, and Fast-Food Restaurants

The majority of eating places in North America include Monosodium glutamate in some form in most of their dishes, unless they specifically state otherwise. However, most reputable establishments can supply a list of the ingredients in their menu items.

Avoiding Monosodium glutamate

Table The Monosodium glutamate- restricted diet provides you with guidelines to avoid added Monosodium glutamate in your food and to reduce your intake of natural forms of glutamate.

Table The Monosodium glutamate- restricted diet

Nitrates and nitrites are used in foods as preservatives, particularly as protection against the deadly bacterium Clostridium botulinum, the cause of botulism, a frequently fatal neuromuscular disease with paralysis caused by the toxin produced by the bacterium, which multiplies within the food. They are also used to give flavor and color to manufactured foods, especially processed meats.

Nitrites and nitrates represent one of the oldest and most effective ways of preserving meats. Without nitrites and nitrates there would be many deaths from the growth of toxic microorganisms. However, the mechanisms that allow these chemicals to kill bacteria may also cause adverse effects in the human body when the food containing the nitrate or nitrite is consumed in excessive quantities. People who are sensitive to the chemicals react at a lower dosage (level) than others, but anyone can develop symptoms if they consume very high doses.

This chapter will provide you with information on when and how nitrates and nitrites enter our foods and how to avoid excessive intake of both chemicals.

Symptoms of Sensitivity

Nitrites preserve the red color of meat by changing the nature of the hemoglobin of the red blood cells. The function of hemoglobin is to carry oxygen throughout the body. When nitrites enter the bloodstream of persons who have eaten the nitrite-treated meat, their hemoglobin is likewise changed if the nitrite level is excessive. This may lead to a condition known as methemoglobinemia with symptoms such as anemia, breathing difficulty, palor, dizziness, and headaches. Because of their small size, infants and young children are more susceptible to nitrite poisoning than adults, and nitrites are not permitted in foods intended for babies under the age of six months.

Nitrites can react with substances called amines in the digestive tract to form nitrosamines, which may be carcinogenic when exposure to the chemicals is excessive and prolonged. There is evidence that consumption of vitamins A, C, and E (antioxidants) in the form of fresh yellow and green vegetables, fish, and plant oils, protects against stomach and intestinal cancer in this situation. Potassium nitrite has been linked to atrophy of the site in the adrenal gland that is responsible for secreting aldosterone, the hormone that maintains the balance of sodium, potassium, and chloride in the blood.

Prolonged exposure to nitrates may cause anemia and inflammation of the kidneys, and ingestion of a large quantity may result in gastrointestinal inflammation with severe abdominal pain, vomiting, vertigo (a sensation as if the world is revolving around the person, similar, but different from, dizziness), muscular weakness, and irregular pulse (nitrate toxicity). A high intake of sodium nitrate has been associated with inhibition of the functioning of the thyroid gland. Nitrates may be converted to nitrites during food spoilage or by intestinal bacteria after consumption. They then have the same effect as nitrites discussed above.

Other reported symptoms include recurrent hives and migraine and nonmigraine headaches.

Nitrates and Nitrites in Foods

The presence of nitrates or nitrites in manufactured foods will be indicated on the label as sodium nitrate, potassium nitrate, sodium nitrite, or potassium nitrite. High levels are found in processed meats such as pepperoni, frankfurters, weiners, sausages, salami, bologna, other luncheon meats, bacon, and ham, as well as in smoked fish and some imported cheeses.

Plants can contain naturally occurring nitrates derived mainly from nitrate-containing fertilizers.

The following plant species tend to have higher levels of nitrates than others do:

Table Summary of the use and effects of nitrates and nitrites in foods provides information about the use of nitrates and nitrites in foods and where you are likely to encounter nitrates and nitrites in your diet. In the United States and Canada, the terms “nitrate” and “nitrite” will appear on product labels; in European countries, the E-numbers will indicate which chemical is present in the food.

People vary in their tolerance of nitrates and nitrites. It is therefore very difficult to give guidelines on how much of a food a sensitive person can eat without having symptoms. The best advice is this: A person who is intolerant to nitrites and nitrates should avoid those foods that have been shown to have the highest levels of the chemicals, as indicated in Table Level of nitrates and nitrites in some meats and vegetables.

Table Level of nitrates and nitrites in some meats and vegetables gives you some idea of the actual levels of nitrates and nitrites in certain foods, demonstrating how these vary among different food types and products. Because the levels of nitrates and nitrites vary according to how much is added to a processed meat, or how much is in the soil in which a plant is grown, it is not possible to provide an accurate measure in each food.

Table Summary of the use and effects of nitrates and nitrites in foods

Table Level of nitrates and nitrites in some meats and vegetables

Note: Nitrates may be converted to nitrites in the mouth and intestine. Thus, the level of the chemical in food does not always reflect the level in the body after digestion.

The average North American diet relies heavily on convenience foods in the form of processed and packaged meals, usually rich in fats and oils. In order to keep these foods safe for the consumer, antioxidants are used extensively to prevent fats and oils from becoming rancid and giving foods an objectionable taste and odor. Butylated hydroxyanisole and Butylated hydroxytoluene are two of the most powerful antioxidants available for this purpose. Although most people have no trouble in consuming these chemicals, a few people develop symptoms when they eat them. This chapter will provide these sensitive people with the information they require to understand how their body reacts to these chemicals, where they are to be found, and how to safely avoid them in their daily diet, without any risk of nutritional deficiency.

Butylated Hydroxyanisole and Butylated Hydroxytoluene do not occur in nature. For the information of readers who like to know exactly what the chemicals they are consuming are made from, Butylated Hydroxyanisole is a mixture of 2- and 3-tert-butyl-4-methoxy-phenol, made from p-methoxyphenol and isobutene. Butylated Hydroxytoluene is made from p-cresol and isobutylene. It was originally developed as an antioxidant for use with petroleum and rubber products. Both products are very effective antioxidants, and for most people they have proven to be safe as food additives.

Butylated Hydroxyanisole and Butylated Hydroxytoluene are often used in combination with other antioxidants such as propyl gallate (where this is allowed), citric acid, or phosphoric acid. The fact that a large percentage of the antioxidant is lost during the processing of food (potato chips and similar snack foods lose 90% of the antioxidant; cookies lose about 35%) means that the quantity consumed is actually much less than what was added to the product during its manufacture. However, when Butylated Hydroxyanisole and Butylated Hydroxytoluene are used in the same product, 20 times the usual amount of Butylated Hydroxyanisole is stored in the body’s fat.

Sensitivity to Butylated Hydroxyanisole and Butylated Hydroxytoluene

Extremely high doses of Butylated Hydroxyanisole and Butylated Hydroxytoluene in experimental animals have consistently resulted in enlargement of the liver. Both kidney and liver functions have been affected. In addition, adverse effects on the brain have resulted in abnormal behavior patterns in experimental animals.

In humans, Butylated Hydroxyanisole and Butylated Hydroxytoluene have been reported to cause rashes and hives in sensitive individuals. Those most frequently affected are aspirin-sensitive, so it is thought that the intolerance to Butylated Hydroxyanisole and Butylated Hydroxytoluene may be due to inhibition of the cyclo-oxygenase pathway of arachidonic acid metabolism, similar to that suspected for salicylate sensitivity. Some reports have implicated Butylated Hydroxyanisole and Butylated Hydroxytoluene in childhood hyperactivity disorders.

In 1978 the United Nations Joint FAO/WHO Expert Committee on Food Additives suggested that daily ingestion of these chemicals should not exceed 0.5 milligrams per kilogram of body weight (e.g., 34 mg for a 68 kg adult). However, intake should be much lower for individuals who are sensitive to these chemicals. Their goal should be to eliminate Butylated Hydroxyanisole and Butylated Hydroxytoluene by reading food labels carefully and avoiding all possible sources of these preservatives. In many countries, Butylated Hydroxytoluene is not permitted in foods intended specifically for babies and young children. Butylated Hydroxyanisole is not permitted for food use in Japan.

Food Products Containing

Butylated Hydroxyanisole and Butylated Hydroxytoluene

Foods likely to contain Butylated Hydroxyanisole and Butylated Hydroxytoluene are

♦ Vegetable oils

♦ Margarines

♦ Foods cooked in or containing vegetable oils, such as

- Potato chips

- Nut meats

- Doughnuts

- Pastries and pie crusts

- Breakfast cereals

- Baked goods

- Salted roasted peanuts

♦ Dehydrated potatoes

♦ Dry breakfast cereals

♦ Dried fruits

♦ Dry yeast

♦ Packaged convenience foods

Additional foods that may contain Butylated Hydroxyanisole and Butylated Hydroxytoluene are

Butylated Hydroxyanisole and/or Butylated Hydroxytoluene may be added to the packaging of cereals, crackers, and other convenience foods to help maintain freshness of the food. Butylated Hydroxyanisole and Butylated Hydroxytoluene will appear on the label if the food contains the preservatives or if they are present in the packaging materials.

The Butylated Hydroxyanisole – and Butylated Hydroxytoluene-Restricted Diet

People who have, or suspect they have, a sensitivity to Butylated Hydroxyanisole or Butylated Hydroxytoluene should follow the guidelines for restricting their intake of these chemicals that are provided in Table.

Table The Butylated Hydroxyanisole and Butylated Hydroxytoluene restricted diet

Color is one of the most important aspects of food presentation. Unless foods are the right color, they are unacceptable to many people. As a result, manufacturers add colors to foods to enhance their market appeal and consumption. This means that we are eating many different chemicals that would probably never enter our bodies, except as additives to manufactured foods. Most of these chemicals do not result in any harmful effects, but some people do react adversely to them. This chapter provides information for those people who are sensitive to the chemicals used for coloring our foods. It also gives details of a diet that such people can follow to avoid all artificial food coloring agents and still obtain complete balanced nutrition from their food.

In addition to artificial colors, many manufacturers use colors derived from natural sources, for example:

♦ Saffron and turmeric as a source of yellow

♦ Beetroot as a red color

♦ Caramel from burned sugar as a brown color

♦ Titanium oxide as a white color

♦ Silver, gold, and aluminum as their natural colors

♦ Chlorophyll from green vegetables as a green color

Colors derived from natural sources are not included in this discussion of causes of food intolerance. Certain sensitive people may experience an allergic reaction to the source of the natural color, for example, an allergic reaction to the plant from which the color was derived. This is then treated as an allergy, details of which can be found in Part I of this book.

ARTIFICIAL FOOD DYES

Tartrazine

Most of the colors listed in Table Use of artificial colors in commercial food products are considered “safe” (Generally Regarded as Safe, or GRAS, designation) by the U. S. Department of Agriculture and have not been cited as a cause of adverse reactions. However, tartrazine and some other azo (nitrogen-containing) dyes have been implicated in adverse reactions. As a result, regulations in the United States require that tartrazine added to foods or medications should be listed separately on the product label. In Canada, at present, this listing is voluntary.

Food manufacturers are not required to give the chemical names or common names of the individual artificial colors used in a food product, except for tartrazine in the United States. As a result, colors usually appear on labels as “artificial color” or simply as “color.”

Conditions Caused by Tartrazine in Sensitive People

Tartrazine (FD&C #5) can cause symptoms resembling an allergic reaction. Tartrazine-sensitive asthmatics tend to experience triggering or worsening of asthma. Hives, itching, nasal congestion and runny nose, blurred vision, purple patches on the skin, and migraine headaches have all been reported as symptoms of tartrazine sensitivity. However, only a few double-blind placebo- controlled trials have indicated that tartrazine is a direct cause of these symptoms.

Tartrazine has been demonstrated to cause a rise in plasma histamine levels even in normal healthy adults when they consume more than 50 milligrams of the dye. Histamine-sensitive individuals react at much lower levels of tartrazine. The mechanism for the release of histamine by tartrazine has yet to be discovered. There is no evidence that an immunologically mediated allergic reaction is involved in this process.

Some people who are sensitive to acetylsalicylic acid (aspirin) also experience an adverse reaction to tartrazine. It is unclear whether dietary salicylates, which are naturally present in a large number of foods (primarily fruits and vegetables), also are involved in this cross-reactivity. Other azo (nitrogen-containing) dyes have also been implicated in adverse reactions.

How Tartrazine Affects the Body

Evidence indicates that tartrazine may initiate the release of histamine from mast cells. Because tartrazine-induced symptoms are similar to those induced by acetyl-salicylic acid, tartrazine may inhibit the cyclo-oxygenase pathway for converting arachidonic acid to prostanoids. However, this mechanism of action has not been proven.

Table Use of artificial colors in commercial food products

Symptoms of Tartrazine Sensitivity

Symptoms reported to be caused or made worse by tartrazine and other azo dyes are

♦ Asthma

♦ Urticaria (hives)

♦ Nausea

♦ Migraine headaches

♦ Allergic vasculitis (purpura)

♦ Hyperkinesis (hyperactivity disorder)

♦ Contact dermatitis

At present, there are no double-blind placebo-controlled trials proving that any of these conditions are caused by tartrazine.

Tartrazine in Foods

Although tartrazine is yellow, it is also used to produce other colors such as orange, turquoise, green, maroon, and brown, so it is not enough to avoid only yellow-colored foods.

Tartrazine-sensitive persons need to avoid

♦ Any food or medication listing tartrazine as an additive.

♦ Any food described as containing color or artificial color unless it is specifically labeled tartrazine-free. This is particularly important for medications.

♦ A food or medication with “tartrazine-free” on the label is safe for a person who is sensitive to tartrazine, but it is no guarantee that the product does not contain other food dyes.

Tartrazine in Medications, Supplements, and Other Items

Tartrazine is in some medications (both prescription and nonprescription) and in some vitamin and mineral supplements. Essential medications should be tartrazine-free. Pharmacies keep a list of manufacturers who produce tartrazine-free products. Some toiletries and cosmetics containing colors may cause contact dermatitis.

Diet Restricted in Tartrazine and Other Food-Coloring Agents

The eating plan in is designed to eliminate tartrazine and other food dyes from the diet and medications. Labeling tartrazine by name, rather than as merely “color,” is mandatory in the United States, but is voluntary in Canada, which means that in Canada, people who are sensitive only to tartrazine must also avoid all commercial foods that have “color” or “artificial color” on the label.

Table Diet free fromtartrazine and other artificial food coloring agents

In the United States, the Department of Agriculture allows ten artificial colors derived from coal tar under the Food Dye and Coloring Act (FD&C). These are listed in Table Artificial food-coloring agents in general use in the United States. Many other countries including Canada have similar regulations.

Citrus Red #2 is restricted to coloring orange skins in fruit not used for manufacture of food products (such as orange juice). Orange B is similar in chemical structure to Amaranth, which is not allowed in the United States but is permitted for use in Canada. Orange B is restricted to the casings and surfaces of frankfurters and sausages. However, because of health risks the sole manufacturer in the United States has stopped producing this dye.

In Canada, a number of colors are listed as “permitted” for use in foods. These are listed in Table Artificial food dyes permitted in Canada.

Artificial Food Dyes in Britain and European Countries

In Britain and Europe, it is somewhat easier for the consumer to identify artificial ingredients on food labels because an efficient system of numbering (“E” numbers) has been developed. Each food additive has a designated number, and a person who knows which food ingredient to avoid simply needs to identify its specific number on the label, which is much easier than looking through a long list of unpronounceable chemical terms. Table Artificial food colors in the european system lists the most common artificial food colors and their E-numbers in the European system.

Table Artificial food-coloring agents in general use in the United States

Table Artificial food dyes permitted in Canada

Table Artificial food colors in the european system

Examples of the Use of Artificial Colors in Foods

Table Use of artificial colors in commercial food products is meant only as an example of the use of artificial colors in commercial food products. Not all manufacturers of the foods use the artificial colors indicated. Some countries ban the use of certain colors. The regulations change frequently, so this table may not be entirely accurate at the date it is being read.

BIOGENIC AMINES INTOLERANCE: HISTAMINE AND TYRAMINE SENSITIVITY

Biogenic amines, including histamine and tyramine, are products of certain amino acids that make up specific proteins. They may be present in both plants and animals consumed as food. In fact, small quantities of biogenic amines are present in almost all foods and usually cause no problems. Large quantities result from microbial activities during rotting of foods and during manufacture of fermented foods such as cheese, wine, vinegar, fermented sausages, soy sauce, and sauerkraut. Large quantities, especially of histamine in foods, cause symptoms of food poisoning in most people; individuals who are considered “intolerant” to biogenic amines experience symptoms when they consume levels that cause no problems in nonsensitive people.

Varying opinions exist on the significance of biogenic amines in non-immunologically-mediated reactions to foods. Because histamine is the most important mediator responsible for the symptoms of “classical allergy” in the Type I (IgE-mediated) hypersensitivity reaction, it is difficult for clinicians to distinguish between reactions due to allergy and those resulting from too much histamine, since the symptoms are the same in both cases. The “classical” symptoms of food allergy, such as urticaria (hives), angioedema (tissue swelling), nasal congestion, asthma (in asthmatics), headaches, oral allergy symptoms, and digestive-tract complaints such as nausea, flatulence, abdominal cramps, and diarrhea, are also typical of histamine intolerance and, to some extent, tyramine intolerance.

HISTAMINE

Histamine is an important physiological fluid in the body. It is always present in plasma, the fluid portion of blood in which blood cells are suspended. The level of histamine in blood goes up and down throughout the day in a specific type of rhythmic variation. Histamine plays important regulatory roles in gastric acid secretion in the stomach, in determining how easily substances pass through blood vessels, in muscle contraction, and in the immune response. It is a key mediator in inflammation, which is the way the immune system protects the body from invasion by infective microorganisms and other events, such as trauma (tissue injury), that are a threat to health.

Histamine is manufactured and stored in a number of cells in the body, particularly mast cells, which occur throughout body tissues, especially mucous tissue. In an allergic reaction (IgE-mediated Type I hypersensitivity), histamine is released from mast cells in vast quantities and is one of the most important inflammatory mediators of the swelling, itching, reddening, and increased movement of blood cells and fluid from inside blood vessels into tissues that are characteristic of symptoms of allergy.

Events other than Type I hypersensitivity can cause the release of histamine from mast cells. Some foods and food additives have shown this ability in the absence of allergy.

Histamine Intolerance

High doses of histamine are toxic for all humans, but individual tolerance determines reactivity to small quantities. Just about everyone who ingests histamine from a contaminated food at a level of more than 2.7 milligrams per kilogram of body weight will show symptoms of “histamine poisoning,” but at lower concentrations only a few sensitive individuals will have a reaction. It is likely that differences in levels of tolerance are of genetic origin, but tolerance can be reduced by disease, especially allergy and autoimmune diseases and medications, such as some antidepressants, some asthma medications, and some antihypertensive drugs.

Cause of Histamine Intolerance

The cause of histamine intolerance is thought to be a defect in the breakdown of histamine. In humans, breakdown of histamine is done by two enzymes, diamine oxidase (DAO) and histamine methyltransferase (HMT), that have different characteristics. DAO occurs predominantly in the lining of the intestine as well as the placenta, kidney, and the thymus gland. HMT has a wider distribution, occurring in the stomach, lung, spleen, kidney, thymus, and particularly the brain. Both enzymes can be slowed or stopped by a variety of compounds, many of which are used as medications. Reduced DAO activity has been the subject of several investigations of conditions such as “idiopathic” (of unknown cause) urticaria and angioedema in which an allergic response has been ruled out. Laboratory findings of increased plasma levels (greater than 2 nanograms per milliliter) of histamine and reduced DAO activity have been suggested as indicators of reduced histamine breakdown and possible enzyme deficiency.

Symptoms of Histamine Intolerance

Symptoms occur when the enzyme system that breaks down histamines cannot keep the histamines at a “normal” level.

Urticaria (hives) and angioedema (tissue swelling) are symptoms that occur in response to excessively high levels of histamine in the body. Rhinitis (nasal congestion) is another symptom of too much histamine. Histamine has also been implicated as an important mediator in some types of headaches that are thought to differ from migraine.

Histamine is the only proven inflammatory mediator to cause itching. Histamine can also cause blood vessels to become more permeable, thus allowing fluid to move from the blood vessels into tissue, causing swelling. It can also cause blood vessels to widen. Sensitive people may experience symptoms such as hypotension (drop in blood pressure) and tachycardia (increased pulse rate) as a result.

Dietary Management of Histamine Intolerance

A histamine-restricted diet has often proved beneficial in reducing total body histamine levels when the cause of the condition is unknown but the symptoms indicate that histamine is the principal mediator. Conditions such as idiopathic urticaria (chronic hives of unknown cause), angioedema (“giant hives”), chronic itching, and some headaches have responded well to a histamine-restricted diet. It is worthwhile to restrict these foods for four weeks in cases where all other treatments have not helped relieve symptoms.

SYMPTOMS INDICATING TOO MUCH HISTAMINE IN THE BODY

Food Sources of Histamine

Histamine is present in most fermented foods. Microbial enzymes convert the amino acid histidine (present as a part of all proteins) to histamine. Any foods that have been subjected to microbial fermentation in the manufacture of the food, such as cheeses, fermented soy products, fermented foods (sauerkraut), alcoholic beverages, and vinegars, contain histamine.

Foods that have been exposed to microbial contamination will contain histamine; the level is determined by how fast the microbial metabolism takes place. Histamine levels will rise to a reactive level long before any signs of spoilage occur in the food. This is particularly important in fish. Bacteria in the gut will start to convert histidine to histamine as soon as the fish dies. The longer the fish remains ungutted, the higher the level of histamine in the flesh.

Some foods, such as tomato, eggplant, and spinach, contain high levels of histamine naturally. In addition, a number of food additives such as azo dyes, particularly tartrazine, and preservatives are known to cause histamine to be released. Some of these (such as benzoates) occur naturally in foods, especially fruits, and may have the same effect as the food additive in releasing histamine. The histamine-restricted diet excludes all the foods that are known to contain high levels of histamine. It also excludes chemicals that can release histamine when they enter the body.

Histamine excess is dose-related. Each function and food adds its own level of histamine up to the person’s limit of tolerance. Once the limit is reached, histamine “overflows” and symptoms result (Figure Diagram Representing a Person with Allergies to Pollen and Cat Dander

Who Has Eaten a Meal Containing Histamine-Rich Foods (Cheese, Tomato, Strawberries) with Wine). The severity of the symptoms depends on the amount of excess histamine in the system.

General Instructions for Avoiding Histamine-Rich Foods

Meat, Poultry, Fish, Egg

Avoid the following:

♦ Fish and shellfish whether fresh, frozen, smoked, or canned, if processing is unknown. If the fish is freshly caught, gutted, and cooked within ½ hour, it may be eaten.

♦ Egg. A small quantity of cooked egg in a baked product such as pancakes, muffins, and cakes is allowed.

♦ Processed, smoked, and fermented meats such as luncheon meat, sausage, weiner, bologna, salami, pepperoni, smoked ham, cured bacon.

♦ Left-overs. Freeze any uneaten protein-based food. Bacteria will quickly act on protein at room and refrigerator temperatures, resulting in histamine production.

Milk and Milk Products

Avoid all fermented milk products, including

Fruits

Avoid

Vegetables

Avoid

Food Additives

Avoid

Seasonings

Avoid

Miscellaneous

Avoid

Medications and Vitamin Supplements

♦ Tartrazine is in some medications (both prescription and nonprescription) and some vitamin supplements. Essential medications should be tartrazine -free.

♦ Pharmacies keep a list of manufacturers who produce tartrazine-free products.

Contact Allergy

♦ Some toiletries and cosmetics containing histamine-releasing substances may cause contact dermatitis. Avoid any that contain cinnamaldehyde, Balsam of Peru, benzoates of any type, sulfites, and dyes.

Figure Diagram Representing a Person with Allergies to Pollen and Cat Dander

Who Has Eaten a Meal Containing Histamine-Rich Foods (Cheese, Tomato, Strawberries) with Wine

The Histamine-Restricted Diet

Table The histamine-restricted diet lists the foods allowed and the foods not allowed in the histamine-restricted diet. This diet excludes all:

♦ Foods with naturally high levels of histamine

♦ Fermented foods

♦ Artificial food colors, especially tartrazine

♦ Preservatives, particularly benzoates and sulphites

Table The histamine-restricted diet

TYRAMINE SENSITIVITY

A sensitivity to tyramine is most common in individuals who

1. Are taking monoamine oxidase (MAO) inhibiting drugs

2. Suffer from migraine headaches

3. Suffer from chronic urticaria

For persons who are taking monoamine oxidase inhibiting drugs, a tyramine -restricted diet is essential. However, these people will not have a lot of food restrictions if they have no previous history of tyramine sensitivity.

TYRAMINE IS PRESENT IN A NUMBER OF FOODS, PARTICULARLY:

Cause of Tyramine Sensitivity

Suppression or relative deficiency of the monoamine oxidase enzyme system that normally breaks down tyramine in the body allows tyramine to rise to a level that results in symptoms. It is excessive undegraded tyramine that causes the symptoms.

A tyramine-restricted diet is especially important for persons taking monoamine oxidase (MAO) inhibitors as therapy. Symptoms indicating excessive tyramine in these people include:

♦ Hypertension (increased blood pressure)

♦ Tachycardia (increased heart rate)

♦ Severe headache

♦ Cardiac failure

Medications that are MAOs include:

♦ Hydrazines (used as antidepressants)

- Isocarboxazid (Marplan)

- Phenelzine (Nardil)

♦ Nonhydrazines

- Pargyline (Evtatin, Eutanyl)

- Tranylcypromine (Parnate)

- Selegiline (Deprenil, Deprenyl, Eldepryl) (used for treatment of Parkinson’s disease)

♦ Antibiotics

- Isoniazid (anti-tuberculosis drug)

Note: Only Parnate, Nardil, and Marplan are in common use at present. The requirement for a tyramine-restricted diet for persons using other MAO inhibiting drugs will be decided by the physician on an individual basis.

OTHER SYMPTOMS REPORTED TO BE DUE TO A SENSITIVITY TO TYRAMINE INCLUDE

The Tyramine-Restricted Diet

For those who are experiencing chronic urticaria or migraine headaches that are considered to be the result of tyramine sensitivity, a reduced tyramine diet is advisable: The response to tyramine is dose-dependent, and the amount of tyramine in foods that causes an adverse reaction will depend on individual tolerance. The number of foods to be restricted initially for these people is usually more extensive than for those who are taking MAO inhibiting drugs, since foods containing lower levels of tyramine are included. Table The tyramine-restricted diet provides details of a tyramine-restricted diet for people who suspect they are intolerant of tyramine.

The Histamine- and Tyramine-Restricted Diet

Some people find that their migraine headaches diminish significantly in severity and frequency when they avoid all food sources of both histamine and tyramine. Table The histamine-andtyramine-restricted diet provides information for such a diet. Four weeks on this diet should be sufficient for a person to determine whether this will provide relief of his or her migraines.

Table The tyramine-restricted diet

Table The histamine-andtyramine-restricted diet

Peanuts are one of the most frequently cited causes of life-threatening anaphylactic reactions. Because of the intense fear among sufferers, parents, and doctors about the risks associated with anaphylactic reactions, peanuts have become the bete noire of food allergy practice. In reality, peanuts have caused very few deaths; deaths from anaphylactic reactions to antibiotics and other medications, injected radio-contrast dyes used in X-ray diagnostic tests, and insect venom from wasp and bee stings vastly outnumber deaths from peanuts. Even when we consider the number of deaths from anaphylactic reactions to foods, tree nuts and shellfish seem to be more frequent culprits than peanuts. However, because of their bad reputation, peanuts have been banned by many airlines, in classrooms from kindergarten onward, and from most places where young children congregate. It is indisputable that whenever that is a risk for anaphylaxis, all possible precautions need to be taken, especially when the victim may be a young child. So, it is probably safer to err on the side of caution, and whenever there is even a slight risk of anaphylaxis, careful avoidance of exposure to even a minute quantity of peanuts is justified. The first thing we need to do, therefore, is to understand the nature of peanut allergy and to be informed about where we can expect to encounter peanuts in the normal diet. That’s what this chapter is all about.

Allergic Reactions to Peanuts

The most important, and most severe reaction to peanuts is anaphylaxis. An anaphylactic reaction involves all systems of the body (is systemic) and, in its severest form, can rapidly progress to anaphylactic shock and death.

Other symptoms of peanut allergy include hives, angioedema (tissue swelling), wheezing, asthma, nausea, vomiting, nasal congestion, itching, and allergic conjunctivitis (itchy/watery eyes). An allergy to peanuts is often lifelong.

People who have been diagnosed as anaphylactic to peanuts must avoid all sources of peanuts. Even when the reaction has been mild on previous occasions, if you have had any reaction at all to peanuts, the potential for a severe allergy exists. Therefore, most doctors advise treating all peanut allergies as if they were life-threatening.

Peanut Allergens

Peanuts are unrelated botanically to nuts that grow on trees, and most people are able to eat a variety of tree nuts, such as walnuts, pecans, Brazil nuts, almonds, cashew nuts, hazelnuts, macadamia nuts, and so on, without difficulty. However, because tree nuts are highly allergenic foods, they are also frequent causes of strong allergic reactions and anaphylaxis. An allergy to nuts should be distinguished from an allergy to peanut and other legumes, otherwise the diet can become stressful and cumbersome if the allergic person avoids all traces of peanuts and all other nuts.

In order to be sure that all sources of peanuts have been identified, especially in manufactured foods, the peanut-allergic person must become familiar with terms on ingredient labels that indicate the presence of peanuts and must be aware of the foods most likely to contain peanuts or peanut protein (Table Terms on food labels that indicate the presence of peanut protein).

A cautionary note here is that sometimes no differentiation is made in the marketing of peanuts and nuts, and the two are often found together in “nut mixtures.” When nuts and peanuts are sold in bulk, a utensil used to handle nuts has often been previously used with peanuts without cleaning in between. In the manufacture of candies, confectioneries, and ice cream, there is frequent cross-contamination between nuts of different species and peanuts, so a person with severe peanut allergy is advised to avoid any product containing “nuts” because of the danger of encountering peanuts inadvertently.

“Mandalona” nut is one of the names given to a manufactured product made from deflavored, decolored peanut meal that is pressed into molds, reflavored and colored and sold as a cheaper substitute for tree nuts such as almonds, pecans, and walnuts. People with peanut allergy must be cautious when consuming any food that may contain such a product.

Table Terms on food labels that indicate the presence of peanut protein

Ingredients That Indicate the Presence of Peanut

Products That May Contain Peanut

Peanut Oil

Research studies have indicated that peanut-allergic adults can tolerate pure peanut oil without any clinical reactions. This is true of oils from any source, including soy. The allergic reactivity occurs to the protein that may contaminate the oil, not to the oil itself. However, people who are anaphylactic to peanut, nuts, or a grain are usually cautioned to avoid the oil derived from the allergenic plant because there may be traces of plant protein in the oil.

Research indicates that refined peanut oil is safe for peanut-hypersensitive people. However, there is no guarantee that any peanut oil is completely free from peanut protein. A person who is anaphylactic to peanut is strongly advised to avoid peanut oil entirely. Cold-pressed oils (also labeled “pure-pressed,” “expeller pressed,” or “unrefined”) in particular should be avoided.

The Peanut-Free Diet (Table The peanut-free diet: foods allowed and foods restricted)

The peanut-free diet omits peanuts and foods containing peanuts. It is important that peanut-sensitive people avoid all sources of if there is even a moderate risk of an anaphylactic reaction to it. However, there is no evidence that even a severe allergy to peanut requires avoidance of all other legumes. Avoidance of legumes such as soy, lentils, dried peas, and beans is necessary only when allergy to the individual foods has been identified. It is also unnecessary to avoid tree nuts, which are botanically unrelated to peanuts. However, because of the risk of contamination of tree nuts, especially nut mixtures, to contain, or to be contaminated, by peanuts, a person who has demonstrated allergy to peanuts is usually advised to avoid nuts of all types in the interests of safety.

Nutrients in Peanut

Peanuts supply niacin, magnesium, vitamin E, manganese, pantothenic acid, chromium, and in smaller amounts vitamin B6, folacin, copper, and biotin. These nutrients are easily replaced by including meat, whole grains, legumes, and vegetable oils in the diet.

The Peanut-Allergic Baby

Protein from peanuts in the mother’s diet can pass into her breast milk and cause allergic symptoms in the breast-fed baby. If the breast-fed infant is allergic to peanut protein, the elimination of all peanut and peanut-containing products from the mother’s diet should be beneficial. If peanut elimination only partially eases the infant’s distress, carefully kept exposure diaries by the mother may isolate other possible dietary or medication irritants.

Table The peanut-free diet: foods allowed and foods restricted

Soy beans are legumes. Soy and peanut (peanut belongs in the same botanic family as soy) are the most allergenic of the Leguminosae family which has over 30 species including fresh and dried peas, fresh and dried beans, all types of lentils, carob, and licorice. Research studies indicate that developing symptoms to more than one member of the legume family is rare. A person who is allergic to peanut and/or soy will not necessarily be allergic to both or other members of the family. Each type of legume must be investigated individually to determine sensitivity to it; avoiding all legumes when only one causes allergy will place unnecessary restrictions on a person’s diet. This can be especially detrimental to the nutritional health of vegetarians, and even more so to that of vegans.

If you have been diagnosed with an allergy to soy, or if you suspect that you may have soy allergy, it is important that you follow a completely soy-free diet, at least for a short period of time. At first glance, this may seem fairly straight-forward-avoid tofu, soy-based beverages (soy milks), and soy sauce, and don’t eat in Oriental restaurants. No big deal! But wait; let us look at the subject of soy a little more carefully. It may not be as simple as you think!

Traditionally, soy is an important part of the Oriental diet, being consumed as tofu in many Chinese and Japanese dishes and, in its fermented form, as soy sauce, miso soup, and similar foods. Tofu and other soy products are an important and necessary part of the vegetarian diet, providing essential protein and other nutrients to replace those found in foods from animal sources. Although soy itself is not a common part of the traditional Western diet, it may surprise some people to realize that all of us have been consuming an increasing amount of soy as an ingredient in many manufactured foods. In fact, it is very difficult to avoid soy entirely. Because it increases the nutrient value of any manufactured food, and adds flavor and texture to the product, it is a very popular addition to many processed and convenience foods. Take a look at the ingredient labels on the packaged foods you have on your shelf-you may be surprised at how many of them list soy. Many breads, pancake mixes, baking mixes of all types, breakfast cereals, packaged soups, and packaged entrees contain soy. Luncheon meats, “cold cuts,” frozen dinners, hamburger patties, meat pies, and sausages contain soy. Soy is often used as a “meat extender,” making the product less expensive (an important selling point in some markets). It is often disguised as “vegetable protein” and other terms in which soy is not immediately apparent. You need to be aware of all of these terms. In some areas, soy-based infant formulas have become very important as alternatives to cow’s milk based formulas when a child has been diagnosed as allergic or suspected to be allergic, to cow’s milk protein. Such formulas are inexpensive, and with the addition of certain essential micronutrients (vitamins and minerals) may provide an acceptable substitute to cow’s milk formulas for feeding in infancy, as long as the child is not allergic to soy, of course.

As you can see, we need to look a little more closely at this food which is becoming so important in our daily lives.

Why Is Soy Important as an Allergen?

Unlike its relative, peanut, soy is a rare cause of anaphylaxis, but it can cause symptoms such as asthma, rhinitis (stuffy nosy), urticaria (hives), angioedema (tissue swelling), and gastrointestinal disturbances. An estimated 43% of babies who are allergic to cow’s milk develop an allergy to soy when given soy-based infant formulas. Allergy to soy protein has many features similar to those of allergy to cow’s milk protein. Like cow’s milk, soy is a frequent contributor to atopic dermatitis (eczema) in atopic children. In infants, soy allergy can cause loose stool and diarrhea, vomiting, abdominal discomfort, irritability, crying, intestinal blood loss, anemia, and slow or nonexistent weight gain (failure to thrive). Respiratory tract symptoms include cough, wheeze, asthma, and rhinitis. Symptoms in the skin include hives and angioedema, as well as eczema.

How Can I Know When Soy is Present in a Food?

Most manufactured foods that contain soy will indicate the presence of soy protein on the label. However, sometimes, the word “soy” may not appear on the label, so persons who are soy-allergic need to become familiar with terms that indicate the likely presence of soy.

On a food label, soy may be indicated by terms such as “textured vegetable protein” or “hydrolyzed plant protein.” Lecithin is often derived from soy and oriental foods such as tempeh, tofu, miso, and bean curd are made from soy which may not be obvious to the consumer who is unfamiliar with oriental foods.

Unlabeled products such as bulk foods, unwrapped breads, and baked goods may contain soy, especially if flour is an ingredient. Persons who are allergic to soy are advised not to purchase these products unless they can find out the specific ingredients.

Table Terms indicating the presence of soy in food products lists the terms most commonly used to indicate the presence of soy.

Table Terms indicating the presence of soy in food products

Terms That Indicate the Presence of Soy Protein

Ingredients That May Contain Soy

The Soy-Free Diet (Table The soy-free diet: foods allowed and foods restricted)

The soy-free diet omits soybeans and all soy products. Soy is widely used in commercial food preparation. People who are soy-allergic need to examine labels carefully as certain brands of the foods listed may not be soy-free. Soybeans are legumes; however, cross-reactivity with other legumes, including peanuts, is rare and should not be assumed without careful investigation. Food-specific diagnosis is necessary to avoid overly restricting the diet.

Table The soy-free diet: foods allowed and foods restricted

Soy Oil

Pure soy oil is not considered to be allergenic, unless contaminated by soy protein in its manufacture. This latter source of soy allergen is difficult to detect in a manufactured product. Therefore, people who are very allergic to soy are advised to avoid soy oil also, although most will tolerate a small amount of the oil in manufactured foods (perhaps up to a teaspoon) without any difficulty.

Soy oil and soy lecithin do not contain detectable soy protein and therefore are not usually antigenic. However, sometimes the refining process does not exclude all soy proteins, so a person who is highly sensitive to soy is advised to avoid soy oil and soy lecithin also. Cold-pressed soy oils (also referred to as “pure-pressed,” “expeller-pressed,” or “unrefined”) are very likely to contain soy proteins.

People who are highly sensitive to soy, or who are in the process of identifying soy allergy, should avoid all products containing soy oil, especially when it is the main ingredient (e.g., soy oil, soy-based margarines, cooking sprays).

Nutrients in Soybeans

Soybeans contribute thiamin, riboflavin, vitamin B6, phosphorus, magnesium, iron, folacin, calcium, and zinc to the diet. However, soy is typically used in commercial products in amounts that are too small to be considered a significant source for these nutrients. Therefore, elimination of soy from the diet does not compromise the nutritional quality of most diets.

Perhaps the most difficult foods to eliminate from your diet are the grains and the flours made from them. Most people eat bread, pasta, baked goods, breakfast cereals, and many snack foods, daily. Just think of your usual routine: for breakfast, cereal, toast, pancakes, or perhaps a toaster pastry; a mid-morning snack that may be a muffin or Danish pastry; for lunch, a sandwich made with bread, perhaps with a bowl of noodle soup; a cookie at mid-afternoon “to keep up your energy” until supper, which may consist of lasagna, spaghetti, or some other pasta dish, or possibly pizza whose crust is, of course, bread. And then before bed, perhaps another cookie. It is difficult to imagine a day without products made from flours and grains.

When you suspect that you may be reacting to wheat or another staple grain, or perhaps have been to the allergist and have been told that your skin or blood test for wheat or other grains is positive, you are going to have to eliminate grains and flours from your diet, at least for a short time. The task at first seems almost impossible especially if you have a hectic lifestyle and rely heavily on convenience foods that need little preparation. It is hard indeed to find prepared foods that do not contain grains and flours. But don’t despair, this chapter is designed to help you through this process.

The first thing we need to do is discuss why grains can cause allergies and how you can best avoid the ones that cause problems. Understanding which part of the grain needs to be avoided will help you have a clearer idea of what to substitute for it. And this is what we want to achieve-not to deprive you of grains and baked goods entirely, but to give you the information that will help you to find acceptable substitutes. This will be especially important if you discover, after the process of elimination and reintroduction, that you are going to have to continue to avoid perhaps wheat and its related grains for the long-term.

Composition of Grains

Although the carbohydrate content of grains is much higher than their protein content, it is the protein that causes the immune system response in an allergic reaction. Wheat is the grain most commonly reported to cause allergic reactions; it is also the grain most common in the Western diet. Allergy to other grains (e.g., oats, rye, barley, corn, rice) is experienced less frequently.

Proteins in Wheat

Protein makes up about 12% of the dry wheat kernel. There are four classes of wheat proteins:

Gliadins

Glutenins

Albumins

Globulins

Gliadins and glutenins form the gluten complex. Gliadins contain as many as 40 to 60 distinct components; glutenins contain at least 15. The molecular size of the protein components in wheat is 10 to 40 kilodaltons, the size considered optimal for triggering a Type I hypersensitivity reaction. Other cereal grains contain similar mixtures of proteins which theoretically could trigger a hypersensitivity reaction.

Allergy to Wheat Proteins

No single protein or class of proteins seems to be responsible for wheat allergy. People who are allergic to wheat tend to react to the albumins and globulins, rather than to the gliadins and glutenins. However, some researchers disagree with this generalization and believe there is more evidence for immune responses to gliadins and globulins than to albumins and glutenins. Interestingly, despite this demonstrable immune reactivity (IgE positivity in RAST [radio-aller-go sorbent test] in most cases), some people show no clinical evidence of wheat allergy when they consume wheat. On the other hand, many people with demonstrable symptoms after consuming wheat are RAST-negative. These findings simply emphasize the importance of elimination and challenge in identifying of a sensitivity to wheat or any other grain before it is excluded from a person’s diet for a prolonged period of time.

The most common symptoms of wheat allergy are asthma (in asthmatics), rhinitis, and conjunctivitis, resulting from flour or grain dust in work environments.

Grains and Celiac Disease

Individuals with gluten-sensitive enteropathy (celiac disease, also called sprue) react to the alpha-gliadin component of gluten. Although researchers have proposed a variety of mechanisms involving immune reactions as the primary trigger of celiac disease, there is no definitive evidence that it is due to an allergy.

Symptoms of celiac disease are diarrhea, weight loss, malabsorption (especially of fat), signs of iron or folate deficiency, sometimes rickets, and indications of other vitamin and mineral deficiencies. Occasionally the condition is accompanied by an itchy rash (dermatitis herpetiformis).

Celiac disease is most definitively diagnosed by a jejunal biopsy (removal and examination of tissues from a specific area of the small intestine) that reveals villous atrophy (flattened, short, or absent villi) and other abnormal changes of the lining of the jejunum. A number of blood tests are available for detecting the presence of a variety of specific antibodies whose presence is indicative of celiac disease. A suspicion that celiac disease is the cause of a person’s symptoms should always be confirmed by laboratory data so that treatment is not undertaken inappropriately. Treatment is lifelong and consists of the strict avoidance of all grains that contain gluten, namely, wheat, rye, oats, and barley. However, it is important to realize that not all wheat intolerance, grain intolerance, or even gluten intolerance is due to celiac disease.

Symptoms of Wheat Allergy

Wheat has been reported to be the provoking allergen in a number of different allergic conditions. Abdominal pain and loose stools beginning within 12 to 72 hours after eating wheat are the most frequently reported symptoms of wheat allergy. In children this pattern often accompanies an allergy to cow’s milk proteins.

Ingested and inhaled wheat flour has been demonstrated to cause asthma in both adults and children and is one of numerous food and environmental allergens implicated in causing eczema. Wheat allergy also may provoke hives and angioedema (tissue swelling, especially of the face). An anaphylactic reaction to wheat has been reported in young infants, but is a very rare occurrence. Exercise-induced anaphylaxis after eating wheat has been reported several times.

Allergy to Other Cereal Grains

The incidence of allergy to other cereal grains and the degree of cross-reactivity among cereal grains is unknown. Allergy to oats, rye, or barley is uncommon, and therefore restricting these grains is rarely necessary except for the treatment of celiac disease. Corn allergy is rare but has been documented in a number of reports, mainly in children. Allergy to rice appears to be equally uncommon. If allergy to any grain is suspected, elimination and challenge should be carried out to confirm the suspicion and determine the specific grain causing the adverse reaction.

Allergy to cereal grains other than wheat is discussed later.

The Wheat-Free Diet

In Western countries, it is difficult to avoid wheat because wheat is a principal ingredient in many commonly eaten foods. Breads, breakfast cereals, crackers, cookies, muffins, pasta, snack foods, luncheon meats, sausages, candies, desserts, cakes, pies, pancakes, waffles, and many other wheat-containing products are the basis of the “convenience foods” associated with the fast-paced Western lifestyle. These products supply the nutrients occurring naturally in wheat, as well as those added in the fortification of wheat flour, namely, thiamin, riboflavin, niacin, and iron. However, they can be obtained from other sources, so a wheat-free diet need not result in the loss of any important nutrients.

Important Nutrients in Wheat

Wheat and wheat products are a significant source of thiamin, riboflavin, niacin, iron, selenium, chromium, and in smaller amounts, magnesium, folate, phophorous, and molybdenum. Many of these micronutrients are added to wheat cereals and flours as fortifiers. Alternative choices of foods to replace these include oats, rice, rye, barley, corn, buckwheat, amatanth, and quinoa, some of which are fortified with micronutrients similar to those found in wheat products. Flours that are suitable as replacements for wheat flour include flours and starches from rice, potato, rye, oats, barley, buckwheat, tapioca, millet, corn, quinoa, and amaranth.

Spelt, kamut, triticale, and flours derived from these grains are too closely related to wheat to be considered safe on a wheat-free diet, unless specifically demonstrated to be tolerated by elimination and challenge.

If you can tolerate rye, oats, barley, corn, and rice, then you can consume baked products, cereals, and pastas using these grains instead of those using wheat. In addition, unusual grains and flours such as millet, quinoa, amaranth, buckwheat, tapioca, sago, arrowroot, soy, lentil, pea, and bean, as well as nuts and seeds, may be used in interesting combinations to make baked products and cereals.

Label-Reading Guidelines for a Wheat-Free Diet

When restricting any food from the diet, you need to become familiar with terms that may appear on product labels indicating that the food is present. Wheat may appear in food products under the terms listed in Table Food products that contain wheat. Hydrolysed plant protein (HPP), hydrolysed vegetable protein (HVP), and monosodium glutamate (Monosodium glutamate) may be made from wheat. However, because the hydrolysis process breaks down the protein to a form that is unlikely to be allergenic, avoiding these products is not considered necessary.

Table Food products that contain wheat

Products That May Contain Wheat

(unless source is declared to be other than wheat)

Wheat-Free Diet

The wheat-free diet on the next four pages omits wheat and foods containing wheat products. (Table The wheat-free diet: foods allowed and foods restricted ). This diet is not suitable for the treatment of celiac disease because it is not gluten-free.

Table The wheat-free diet: foods allowed and foods restricted

‘Avoid these products unless the source is known not to be wheat.

Grain Allergy

Ideas for Substituting Grains in Selected Meals

Breakfast Foods

Cooked grains make enjoyable breakfast cereals when fruit, honey, nuts, or seeds are added.

Cook amaranth, millet, quinoa, and buckwheat grain like brown rice: Combine a cup of grain with 2 1/4 or 2 1/2 cups of water.

Bring to boil, lower heat, and simmer for 45 to 60 minutes depending on the degree of “doneness” desired.

You can cook the grains in large batches (for example, 4 cups of grain), freeze it in 1-cup quantities, can reheat it in the microwave. Cooked grain provides the basis for an instant breakfast cereal.

Soup

Commercial soups are frequently thickened with restricted grains or contain restricted noodles or pasta. Bouillon cubes may contain grains. Homemade meat, poultry, or vegetable soup stocks are safe. Meat drippings can be chilled, the fat lifted off, and the meat juices used for a soup base. They may be thickened with tapioca, arrowroot, or starch if desired.

Easy Vegetable Stock

Use any combination of washed and trimmed onion skins, potato and carrot peelings, celery strings and leaves, parsley stems, green bean and tomato ends, outer lettuce leaves. Save trimmings in a plastic bag in the fridge or freezer. Cover with water in a saucepan. Add a bay leaf and pepper and bring to a boil. Simmer for 30 minutes. Strain and add salt to taste. Use instead of consomme or soup base. Freeze leftovers in ice cube trays.

Desserts

The following desserts are allowed:

♦ All desserts and baked goods made with allowed ingredients

♦ Plain gelatin desserts

♦ Fruit ices

♦ Popsicles

♦ Ice cream made with allowed ingredients but not ice cream cones

♦ Sherbet

Breads and Baked Goods

No single flour will replace wheat flour in a recipe. The texture will be different when you use a non-wheat flour, but more importantly, any baked product that is risen as an important part of its production will not retain its risen shape as it cools unless gluten is part of its structure. Non-gluten grains will drop noticeably as they cool. You can substitute alternative grains for wheat in a combination that provides an acceptable texture to the product, but you must adjust for the dense nature of the finished product.

EXAMPLES OF ALLOWED FLOURS AND STARCHES

Substitutes for Restricted Flours in Recipes

In place of restricted flours in recipes, combinations of alternative flours make better cakes, cookies, breads, pancakes, and waffles than a single flour alone. A combination of rice, soy, potato, and arrowroot (or tapioca,) starch makes an acceptable bread mix. Use 1 cup of the mix in place of 1 cup of wheat flour in recipes.

Combining “light,” “intermediate,” and “heavy” flours in the ratio on the next page will give a better baked product than using any single flour.

Combine in a ratio:

1 cup of the combined flours will substitute for 1 cup of any restricted flour in recipes, but some adjustments in liquid levels or cooking times may be required to obtain an equivalent texture, especially in breads.