5.3 Individual Foods

Pages 265-281 from The Food Intolerance Handbook
Copyright (c) Sharla Race. All rights reserved.

5.3 INDIVIDUAL FOODS

Milk

Problems with milk are extremely common. Milk contains a number of proteins, such as casein, that can lead to allergies. Milk also contains lactose which many people cannot digest and this also leads to problems.

Lactose is the sugar in milk and it requires the enzyme lactase to digest it. Lactose intolerance is quite common and some have suggested that it arises because we were never intended to consume milk after infancy. There are tests available to identify both milk protein allergy and lactose intolerance—your doctor will be able to advice on these if you wish to find out more.

For many the relief obtained from a milk free diet is so extensive that they simply give up all forms of milk. Milk is in fact not a natural food. It is produced by females for their young and was never intended as a food for those beyond infancy. Do you know of any animal that habitually drinks the milk of another animal especially when it is grown up?

The main symptoms linked with milk problems are recurring digestive problems such as excessive gas, bloating, cramps, pain, diarrhoea, constipation, and recurring catarrhal problems. It has also been linked with:

Arthritis, Asthma, Chest complaints, Colds, Dermatitis, Ear problems, Hyperactivity, Irritability, Learning difficulties, Migraine, Sinusitis, Sleep disorders.

Rousquet et al reported that between 7 and 29% of asthma sufferers have a milk sensitivity. They also found it was often a cause of rhinoconjuctivitis in young children and may be implicated in serious otitis media.[Rousquet J, Chanez P, Michel F-B. The respiratory tract and food hypersensitivity. In: Metcalfe DD, Sampson HA, Simon RA. (eds) Food Allergy: Adverse reactions to foods and food additives, 2nd ed. Blackwell Science 1997.] Elimination diets worked for migraine sufferers in a study by Mylek and the food most usually implicated was cow's milk.[Mylek D. Migraine as one of the symptoms of food allergy. Pol Tyg Lek 1992;20-27;47(3-4):89-91.]

Kahn et al in a study of one hundred and forty six children referred for sleep disturbance identified fifteen whose sleep problems were resolved within five weeks of starting a diet free from cow's milk. In a subsequent challenge, the sleep disturbances returned within four days of reintroducing the cow's milk.[Kahn A, Mozin MJ, Rebuffat E et al. Milk intolerance in children with persistent sleeplessness: a prospective double blind crossover evaluation. Pediatrics 1989;84:595-603.]

In children the two major symptoms that appear early on are gastrointestinal upsets and dermatitis. Some children appear to grow out of a milk allergy but some don't. James and Sampson found that those who retain a sensitivity to milk often have a decrease in skin disorders but an increase in gastrointestinal and respiratory symptoms.[James JM, Sampson HA. Immunolgic changes associated with the development of tolerance in children with cow milk allergy. J Pediatr 1992;121:371-77.]

To test for a milk sensitivity avoid all milk, foods made from milk, and foods that contain milk products. Give yourself at least five milk free days before testing. If you can manage it, live without milk for two weeks and experience the effects fully.

Milk causes many people problems solely because it is consumed many times every day. Giving yourself a holiday from it will be an interesting, and hopefully, beneficial experience.

If milk has been causing you problems, the good news is that you should notice an improvement quite quickly. If your symptoms disappear or if you test and have a negative reaction then decide on a strategy:

As some people are sensitive to the chemicals the cow has ingested or been treated with, it is always safest to start your test with an organic milk. If you find you have a problem, your options are:

to give up milk completely,
test various products to see what you can tolerate (for example, you may be able to eat yoghurt and cheese but not drink milk; milk in baked products may be okay but not on its own; evaporated milk may be okay but not whole milk) or
find out if your problem is lactose intolerance and take digestive enzymes to help if you wish to continue with milk.

What you decide to do will depend in part on how addicted to milk you are, not so much physically but by habit. At the outset giving up milk seems very strange and awkward because it seems to be everywhere and even your daily tea and coffee has to taste different. All of these problems can be overcome but it does take time to make the adjustment. Unless you have an allergic response to milk, there is nothing wrong with testing out how much milk in its different forms you can tolerate. If your unpleasant symptoms return this will provide you with the motivation you need to give it up completely.

You can try alternative milks such as goat and sheep—some people can tolerate these, others can't. There are also soy, nut, rice and oat milks now available. Initially you may find these unpalatable (your taste buds are still expecting cow's milk) but you will soon adapt or learn to do without.

Soya milk is often used as a substitute for cow's milk and was considered safe for children intolerant of milk. This is no longer thought to be the case. Lee and Heiner found that about one-fourth of those sensitive to cow's milk went on to become allergic to soy protein.[Lee EJ, Heiner DC. Allergy to cow's milk 1985. Pediatrics in review 1986;7(7):195-203.] Various alternatives exist—check with your doctor as to which is the safest option for your child.

Reactions to cheese only may indicate a sensitivity to food chemicals such as tyramine and histamine rather than to milk—see the section on Amines.

If you need to avoid milk in all its forms, the foods and ingredients you need to avoid will probably include:

Milk in any form including dried milk, butter, buttermilk, casein, caseinate (all forms), cheese, cream, curds, custard, ghee, hydrolsates, ice cream, lactalbumin, lactose, milk chocolate, natural flavouring, rennet, sour cream, whey, white chocolate, yoghurt.

Gern et al reported casein as a cause of allergic reactions for some individuals who had been eating so called “non-dairy” products.[Gern JE, Young E, Evrard HM, Sampson HA. Allergic reactions to milk-contaminated "nondairy" products. New Eng J Med 1991;324:976-79.] Casein and caseinates appear in a wide range of processed foods as they are used as extenders and tenderisers and, also, to nutritionally fortify certain foods so check labels carefully. They can be found in foods ranging from meat and fish products, coffee whiteners, salad dressings and bakery glazes.

Meats purchased from deli counters can pose a problem arising from cross contamination if cheese and other milk products are stored and/or sliced nearby. Bread, cakes and pastries from bakeries or bakery counters in large stores are generally not required to have ingredients labels—before buying any item that does not carry a label, check with a member of staff whether the item is milk free. To be 100% safe you would need to do this every time you make a purchase as ingredients do change.

You will need to carefully check any processed food including:

Meats and breads, desserts, and margarine.
Non-dairy products including ice creams.
Sweets and any snack foods.
Beware also of the terms “emulsifier” and “protein” as these may be milk based.
Brown sugar flavouring, caramel flavours, and high protein flour may all indicate the presence of milk protein.

Many people are very concerned about a milk free diet for fear of not getting sufficient amounts of calcium. It is quite possible, as vegans have proved, that the body's calcium requirements can be met from other foods. Foods that are high in calcium include canned salmon with bones, sardines, greens, broccoli, and tofu. You can also ask your doctor if you should take a calcium supplement.

If you are lactose intolerant and want to continue using milk you may have some options to total avoidance although this will depend on the degree of your sensitivity:

Digestive enzymes could help.
Some people can tolerate small amounts of lactose such as that found in ½ cup of milk.
Foods containing lactose are sometimes better tolerated if eaten with other foods.
It is possible that you can tolerate cooked milk products but not, for example, milk on your cereal.
Eating smaller amounts of lactose food over a day rather than one single large amount may be easier for you.
You may be able to eat some products like yoghurt without difficulty.

It will be a case of experimentation until you find the level that is acceptable to you—balancing any occurrence of symptoms with the amount and type of milk that you eat.

Peanut

Seeds and nuts

Nuts and seeds present a hidden danger for many. Because of their versatility they are found in a wide range of processed foods and restaurant meals including meat dishes, breakfast cereals, sweets, spreads, sauces and desserts. Sicherer identifies tree nuts as one of the most common foods that causes problems for both children and adults.[Sicherer SH. Manifestations of food allergy: evaluation and management. Am Fam Physician 199915;59(2):415-24,429-30.]

Nut and seed allergies usually present in childhood but intolerance can develop at any time especially as they are now, often inadvertently, consumed in greater and more regular quantities. A sensitivity to more than one could indicate a more general problem with salicylates and/or amines.

All varieties of seeds and nuts have at some time been implicated in a food intolerance or allergy problem. Reactions to nuts and seeds have included:

Abdominal cramps, Anaphylaxis, Angioedema, Breathing difficulties, Coughing, Dermatitis, Diarrhoea, Eczema, Facial swelling, Gastrointestinal problems, Hypotension, Rhinoconjuctivitis, Tingling in the mouth, Urticaria, Vomiting.

Guariso found that some young people's migraines were triggered by hazelnuts.[Guariso G, Bertoli S, Cernetti R, Battistella PA, Setari M, Zacchello F. Migraine and food intolerance: a controlled study in pediatric patients. Pediatr Med Chir 1993;15(1):57-61.] Ewan's study found allergies to brazil nut alone, brazil nut plus other nuts, almond, almond plus other nuts, hazelnut, hazelnut plus other nuts, walnut, cashew nut.[Ewan PW. Clinical study of peanut and nut allergy in 62 consecutive patients: new features and association. BMJ 1996;312:1074-78.]

Sicherer et al in a study of those with peanut and tree nut allergies found that out of one hundred and twenty two people: Sixty eight had reactions only to peanut, twenty to only tree nuts, and thirty four to both .

Of those reacting to tree nuts, thirty-four had reactions to one nut, twelve to two nuts, and eight to three or more nuts. The most common tree nuts to cause reactions were walnut, pecan and almond. Eighty nine percent of the reactions involved the skin (urticaria, angioedema), 52% the respiratory tract (wheezing, throat tightness, repetitive coughing, dyspnea), and 32% the gastrointestinal tract (vomiting, diarrhoea).[Sicherer SH, Burks AW, Sampson HA. Clinical features of acute allergic reactions to peanut and tree nuts in children. Pediatrics 1998;102(1):e6.]

Coconut has been implicated in skin problems.[Stricker WE, Anorve-Lopez E, Reed CE. Food skin testing in patients with idiopathic anaphylaxis. J Allergy Clin Immunol 1986;77:516-519.
] Allergy to coconut was identified in a three-year old boy—he experienced abdominal pain, vomiting, oral allergy syndrome, and swelling of the eyelids immediately after oral contact with a coconut sweet. One year later, after eating a small portion of fresh coconut, he suffered sudden abdominal pain, vomiting, oral allergy syndrome, and swelling of the eyelids.[Tella R, Gaig P, Lombardero M, Paniagua MJ, García-Ortega P, Richart C. A case of coconut allergy. Allergy. 2003 Aug;58(8):825-6.]

Like the pistachio nut, the cashew nut contains oleoresins similar to those found in poison ivy and oak which can lead to contact dermatitis, stomach problems and other allergy type symptoms. The problems seem to manifest more in adults than in children. Meysman et al describe how one individual experienced severe anaphylaxis, angioedema, hypotension and shock after eating yoghurt and muesli. Investigations identified that the near fatal allergic reaction was caused by a pine nut allergy.[Meysman M, Schelfaut D, Vincken W. A not so healthy muesli: a case report. Acta Clin Belg. 2009 Jul-Aug;64(4):366-8.]

Cross-reactivity between tree nuts and other foods and pollens have been recorded. Eriksson et al found coconut hypersensitivity in twenty two (out of three hundred and eighty) birch-pollen allergic individuals and 26% reported reactions to walnut. In respect of hazelnuts, they found those with birch-pollen allergy more often reported hypersensitivity to hazelnuts (53%) than those without pollen allergy (7%).[Silverman K, Evans SM, Strain EC, Griffiths RR. Withdrawal syndrome after the double-blind cessation of caffeine consumption. New Eng J Med 1992;327:1109-14.]

Vocks et al found the degree of cross-reactivity among kiwi, sesame seeds, poppy seeds, hazelnuts, and rye grain was found to be very high in the people studied but the degree and exact type of cross-reactivity varied.[Vocks E, Borga A, Szliska C, Seifert HU, Seifert B, Burow G, Borelli S. Common allergenic structures in hazelnut, rye grain, sesame seeds, kiwi, and poppy seeds. Allergy 1993;48(3):168-72.]

Eating large amounts of hazelnuts can lead to an increase in nickel intake which potentially could lead to aggravating symptoms usually identified by the individual as being caused by nickel.[Flyvholm MA, Nielsen GD, Andersen A. Nickel content of food and estimation of dietary intake Z Lebensm Unters Forsch 1984;179:427-31.]

Caubet et al describe three cases of severe snack seeds allergy in children:

A six-year old girl experienced oral itching, swelling of the lips and face, vomiting, and breathing problems within five minutes after eating a handful of sunflower seeds.
An eleven-year old boy experienced an anaphylactic reaction within a few minutes after eating pumpkin seeds.
A seven-year old boy experienced two episodes of generalized urticaria and facial swelling and a third episode with angioedema, wheezing, and acute breathing difficulties within fifteen minutes after repeatedly consuming small amounts of sunflower seeds.[Caubet JC, Hofer MF, Eigenmann PA, Wassenberg J. Snack seeds allergy in children. Allergy 2010 Jan;65(1):136-7.]

I don't know whether nuts and seeds are potentially more allergenic than other foods but, because of the large number of reported cases of anaphylactic shock, I do not recommend testing nuts and seeds when on your own. If you suspect nuts or seeds are a problem please discuss testing with an allergist or doctor. If an allergy test is negative and you still believe that some nuts and/or seeds are a problem then eliminate them from your diet and test them but ensure that someone is present who understands what needs to be done in case of anaphylaxis (this advice is based on the fact that allergy tests are not always 100% reliable)

Some of the more common nuts and seeds: Almond, brazil, cashew, coconut, hazelnut (or filbert), macadamia, pecan, pine, pistachio, poppy seed, pumpkin seed, sesame seed, sunflower seed, sweet chestnut, walnut.

You can eliminate and test each nut and seed separately or eliminate them all and then introduce them one by one during the testing phase. Remember that reactions to more than one of those high in amines or salicylate could indicate a much more general problem. Those that are particularly high in these are noted below (full details can be found in the relevant chapters).

Those high in salicylate are almonds, brazil nuts, desiccated coconut, macadamia nuts, pine nuts, pistachio, sesame seeds, walnuts.
Those high in amines are brazil, hazelnut, pecan, and walnut.

Sicherer et al found that accidental ingestions are common and occur most frequently outside of the home. Some of the ways in which accidental ingestion took place were as a result of:

Sharing food
Hidden ingredients
Cross contamination.[Sicherer SH, Burks AW, Sampson HA. Clinical features of acute allergic reactions to peanut and tree nuts in children. Pediatrics 1998;102(1):e6.]

Particular attention needs to be drawn to sesame seeds as allergic reactions to sesame seeds in the west have become increasingly commonplace since their introduction into processed food including burgers at many fast food outlets and the increase in the number of “exotic” meals now being eaten both in restaurants and as ready-made meals.

Anaphylaxis, angioedema, atopic dermatitis, allergic rhinitis, and bronchial asthma have all been caused by sesame seeds. Other reactions are possible and, even, likely. Remember that these vary from individual to individual. My husband, on testing sesame seeds experienced a total high which a few hours later had changed into overwhelming feelings of depression, fuddled thinking, tiredness and overall ill health. Until that time he had not known that sesame seeds caused any problems. It took more than three days for the symptoms to abate.

If sesame seeds are a problem, extreme vigilance is needed with processed and restaurant food as sesame can often be a hidden ingredient. Kagi and Wuthrich reported on a case of anaphylaxis that was caused by sesame seed in a falafel burger.[i] Food cooked in oil must always be suspected as reactions including anaphylaxis have been reported from sesame oil.[ii],[iii]
[i] Kagi, MK; Wuthrich, B. Falafel-burger anaphylaxis due to sesame seed allergy. Lancet 1991;338: 582.
[ii] Chiu, JT; Haydik, IB. Sesame seed oil anaphylaxis. J Allergy Clin Immunol 1991;88:414-415.
[iii] Kanny G, De Hauteclocque C, Moneret-Vautrin DA Sesame seed and sesame seed oil contain masked allergens of growing importance. Allergy 1996;51(12):952-7.

Sesame oil finds its way into other products such as ointments and absorption through the skin can also lead to problems. Sesame oil, as a constituent of a zinc oxide liniment, was found to be the cause of contact dermatitis in fifteen out of ninety eight people with leg ulcers who had been using the liniment.[i],[ii]
[i] Van Dijk E, Neering H, Vitányi BE. Contact hypersensitivity to sesame oil in zinc oxide ointment. Ned. Tijdschr. Geneeskd. 1972,116:2255.
[ii] Van Dijk E, Neering H, Vitányi BE. Contact hypersensitivity to sesame oil in patients with leg ulcers and eczema. Acta Derm.-Vener. 1973;53:133.

Malten found in one hundred cases of leg ulcers, eleven people showed positive patch test reactions to a paste containing 40% sesame oil and a higher proportion showed positive reactions to 100% sesame oil.[Malten, KE. Sesame oil contact hypersensitivity in leg-ulcer-patients. Contact Dermatitis Newsletter 1972;(11):251.]

Soya

Reactions to soya have become more widespread mainly due to the increasing use of the soya bean in processed food. If you are shaking your head and saying you never eat any—check the foods you most commonly buy that are pre-prepared especially bread. Soya, and the emulsifier lecithin, are commonly used in processed foods ranging from soups to chocolate, and most mass produced bread contains soya. For many it truly is a hidden problem.

It is easy to be blasé about the safety of ingredients that appear to play a very small role in a food such as soy lecithin in bread but the reality is that soy lecithin has caused an anaphylactic reaction in a child[Renaud C, Cardiet C, Dupont C. Allergy to soy lecithin in a child. J Pediatr Gastroenterol Nutr. 1996 Apr;22(3):328-9.] and so, for some people, is potentially very dangerous.

A thirty-eight year old man developed an anaphylactic reaction with flushing, generalized urticaria, conjunctival redness, and breathing problems three hours after eating cold Chinese noodles. He had avoided natto for the previous year as he had once experienced anaphylactic reactions half a day after eating natto. Skin prick tests were strongly positive for natto and the soup of cold Chinese noodles. The tests were also positive for poly gamma-glutamic acid (PGA), which is a major constituent of natto mucilage, an ingredient of the noodle soup.

The man was diagnosed with late-onset anaphylaxis to PGA contained in natto and the cold Chinese noodle soup. The delayed reaction was thought to be due to a delayed absorption of PGA which has to biodegrade to peptides sufficiently small enough to be absorbed in the bowel. Inomata et al note that PGA has recently been applied to a wide range of fields such as foods, cosmetics, and medicine and that anyone with a sensitivity to PGA of natto should avoid not only natto but also other materials containing PGA.[Inomata N, Chin K, Nagashima M, Ikezawa Z. Late-onset anaphylaxis due to poly (gamma-glutamic acid) in the soup of commercial cold Chinese noodles in a patient with allergy to fermented soybeans (natto). Allergol Int 2011 Mar 25.]

Sensitivity to soya has led to cases of asthma, rhinitis, urticaria, angioedema, and digestive problems.[Koerner CB, Sampson H. Diets and Nutirtion. In Metcalfe DD, Sampson HA, Simon RA. Food Allergy: Adverse Reactions to Foods and Food Additives. Blackwell, 1991.] The symptoms experienced will vary from individual to individual but all of the following have been noted:

Abdominal pain, Acne, Anaphylaxis, Angioedema, Anxiety, Asthma, Bloating, Breathing difficulties, Colitis, Conjunctivitis, Dermatitis, Diarrhoea, Eczema, Heart palpitations, Hives, Hypotension, Itching, Lethargy, Mouth sores, Rhinitis, Urticaria, Vomiting, Wheezing.

In the last few years there has been much publicity about the health benefits of soya. You should know that some researchers now believe that soya products increase the risk of thyroid disease and suggest that only small amounts are eaten.

To test for a soya sensitivity you need to eliminate it from your diet in all its forms for at least five days and then test it in its most natural form. Food terms that indicate the presence of soya include: Edamame beans, HVP, lecithin, miso, natto, shoyu sauce, soy bean sprouts, soya flakes, soya milk, soya protein, soy sauce, soya flour, tamari, tempeh, tofu, TVP, yuba.

You also need to avoid foods containing vegetable oil that do not state which oils are used.

Some people can tolerate soya oil but as cases of anaphylaxis have been reported it is best avoided.[Dueñas-Laita A, Pineda F, Armentia A. Hypersensitivity to generic drugs with soybean oil. N Engl J Med. 2009 Sep 24;361(13):1317-8.] Watch out for hidden soya, including lecithin, in processed foods. This requires very diligent label checking as it is found in so many foods—never assume something is safe. The following terms may also indicate the presence of soya:

Bulking agent, emulsifier, flavourings, hydrolysed vegetable protein (HVP), protein, protein extender, stabiliser, starch, textured vegetable protein (TVP), thickener, vegetable broth/protein/stock, vegetable starch, vegetable gum.

If you find you only react to fermented soya products you may in fact have an amine sensitivity rather than one to soya (see the section on Amines).

One of the hardest aspects of a soya sensitivity is avoiding the hidden soya so if you find you are very sensitive you will need to check and double check all foods not prepared by yourself—do not trust anyone else to check for you.

Like many other foods, soya is also present in many non-food items. If you are very sensitive to soya these may also cause you a problem. Steinman lists some possible non-food sources of soya including:

Adhesives, blankets, body lotions and creams, dog food, enamel paints, fabrics, fabric finishes, fertilisers, flooring materials, lubricants, paper, printing inks, soap.[Steinman HA. Hidden allergens in foods. J Allergy Clin Immuno 1996;98(2):241-50.]

Falleroni and Zeiss report on a case of a six-year old boy who reacted to soy bean dust from a bean bag.[Falleroni AE, Zeiss CR. Bean bag allergy revisited: a case of allergy to inhaled soybean dust. Ann Allergy Asthma Immunol 1996;77(4):298-302.]

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