Posts Tagged ‘Atopics’

Elimination diet
An elimination diet is a method of diagnosing idiopathic food intolerance (see p. 74) and certain other

forms of food sensitivity where indirect tests, such as skin tests, are unhelpful. The principle of the

elimination diet is very simple. It begins by removing from the body every food that could possibly

cause a reaction, and seeing if this produces a symptom-free state. If it does, the elimination diet

then presents the body with different foods, each in its pure form, to see which ones cause symptoms.
While the principle is simple, the practicalities of the elimination diet can be much more complex, and

it is vital to understand the details fully before you start. There is absolutely no room for

‘cheating’ with this diet – one mouthful of cake is enough to ruin the whole thing. You need forward

planning and a lot of self-discipline, backed up by a good stock of the permitted foods for moments

when hunger overcomes you. Some cooked foods, stored in the freezer in individual portions for quick

defrosting, are a great help.
Doing an elimination diet incorrectly is not just a waste of time. Some people acquire new

sensitivities during the diet, which may make it very much more difficult to do a second elimination

diet. So plan ahead and get it right first time.
The planning stage
First of all, start an accurate symptom diary. This will give you a precise picture of how bad things

are now, before you try any dietary measures. A detailed daily symptom record, covering a period of

about two weeks, can be very useful, whether or not you actually do an elimination diet. It can serve
as a baseline against which to judge the effects of any future treatment.
Before you begin an elimination diet, you must see your doctor and ask if it is safe for you to do the

diet. Read through the next four pages first – the more you know about elimination diets, before

talking to your doctor, the better.
There are some conditions where, although an elimination diet can be very helpful, it should not be

attempted without full medical supervision. Two main causes for concern exist:
•    For people who are undernourished to start with, the elimination diet may be too demanding – it

is difficult to eat enough calories during the first few weeks of the diet, unless an elemental diet is

used as a supplement (see box on p. 196). If you are underweight, or have rheumatoid arthritis or

Crohn’s disease, the possible use of elemental diets is something you should discuss with your doctor.
•    With certain diseases (see list that follows), the testing stage may induce severe symptoms.

Sometimes these can be life-threatening and need immediate medical attention.
Medical supervision during food testing is recommended for anyone with these conditions:
•    Crohn’s disease – testing can bring on a prolonged relapse. Very small amounts of food should

be tested initially, and the quantity slowly increased.
•    Brittle asthma – after a period of avoidance, a culprit food can bring on a severe and possibly

life-threatening asthma attack.
•    Atopic eczema – the risk of reactions is higher if skin tests are positive (see p. 198).
•    Chronic urticaria – occasionally there is an immediate reaction to an offending food. It is

advisable to test foods in very small portions oust a mouthful) at first. If there is no reaction

whatever after four hours, a normal portion can be tested.
Note that an elimination diet is not suitable for anyone with true food allergy (see p. 62). If you

have ever had an immediate reaction to any food, or any symptoms in the lips or mouth, testing foods

can be dangerous. Caution is also necessary if you have ever reacted to a food with violent vomiting

and/or diarrhoea some hours after eating. This could be due to an infection, of course, but such

symptoms can also, very rarely, result from true food allergy (see p. 64). Finally, if you have ever

suffered anaphylaxis from any cause – not just food –the testing phase of an elimination diet might be

risky. Ask your doctor’s advice.
Once you have your doctor’s permission to try the diet, work out how the stages of the diet will fit in

with your life over the weeks or months ahead. Until it is over, eating food made by other people is

virtually out of the question. When eating away from home, you must either take prepared food with you,

or just eat very simple foods – such as permitted fruits or nuts. Think about the practicalities of

carrying food for meals away from home.
Finally, devise the diet you will follow during the exclusion phase (see right), locate shops that sell

the more unusual foods, and stock up on everything required.
You will continue to eat a lot of these foods for the first few weeks of the testing stage, so you may

want to buy extra stocks and refrigerate them for
longer storage, especially if the sources of supply are some distance from your home.
Note that food ingredients in medication could interfere with the results of the elimination diet. For

example, if you are very sensitive to maize (corn), the cornflour that is added to many antihistamines

and other drugs could create much confusion. Food-free medicines are available – talk to your

pharmacist about this initially, then to your doctor if you need a different prescription.
The exclusion phase
During the first part of an elimination diet, you exclude all the foods that you normally eat, plus any

closely related foods. For example, if you normally eat oranges, you should avoid all other citrus

fruits, including lemon, limes and grapefruit, even though you do not normally eat these. If you

normally eat plenty of broccoli, you should omit all its relatives, such as cabbage, kale, spring

greens and cress.
The best way to conduct the exclusion phase is not to follow a set menu, such as the well-known

‘Iamb-and-pears’ diet, but to draw up your own list of permitted foods. This can include foods that you

have never eaten before, and those you eat rarely.
The list should run to at least ten items. One problem with an exclusion phase that consists of only

two foods (as in the ‘Iamb-and-pears’ diet) is that you are bound to eat a huge amount of these foods.

This is asking for trouble if you have a tendency to food intolerance, because you can quite quickly

become sensitive to new foods if eating them in large amounts.
Your list of permitted foods should include:
Some starchy items. These are essential for keeping hunger at bay: try some of the more exotic root

crops, such as sweet potatoes, yams, dasheen and cassava. These are available in large supermarkets and

in small shops catering to Indian, African, Chinese and Caribbean communities. (Cook them as you would

potatoes. In the case of cassava, it must be boiled, not baked.) You can also eat parsnips, turnips,

chestnuts and pumpkin. Tapioca, sago, buckwheat, millet, quinoa and sorghum are other possibilities: a

health-food shop is a good source of some of these. Use rice if it is not normally part of your diet.

Do not include sweetcorn or maize meal, even though you do not normally eat these –corn products are

very widely used in packaged food, and sensitivity to corn is not uncommon.
Several fruits and vegetables that you don’t normally eat. Exotic produce such as mangoes and okra can

help a lot in keeping the diet tasty. Avocados, which are very rich and nutritious, can be included if

you don’t eat them often.
Some protein items. For carnivores, this is the easy part – any meat that you don’t normally eat is

suitable. Consider turkey, rabbit, pigeon or game, for example. (Soak rabbit meat in salt water

overnight to get rid of the strong taste, if you dislike this.) Strict vegetarians have more problems

here, since goat’s milk, sheep’s milk and all birds’ eggs are disallowed – their proteins are much too

similar to those of normal milk and eggs. Soya products such as tofu should definitely be avoided, as

should other pulses initially, because sensitivity to these is a possibility among vegetarians. Quorn,

or mycoprotein, could affect anyone sensitised to yeast, and should not be included. Fortunately the

exclusion phase is fairly brief, so a low intake of protein will not be disastrous. Including some nuts

on your list of permitted foods will help, as these contain protein. If nuts are part of your normal

diet, you may have to resort to rarely eaten kinds such as macadamias, cashews or pistachios.
Elemental diets
An elemental diet is a powder that contains all the nutrients the human body needs but is free from the

substances in food that provoke allergic and intolerance reactions. It is mixed with water to create a

complete substitute for food. Originally designed for space travel, this totally synthetic form of

sustenance is also known as ‘the astronaut’s diet’.
Used alone during the exclusion phase, elemental diets are the basis for the ultimate – and

theoretically foolproof – elimination diet. They sustain you through the exclusion phase, and continue

to provide your basic diet during the testing phase.
For anyone with multiple food sensitivity, using an elemental diet circumvents the problem of finding

ten or more safe foods with which the elimination diet can begin.
Those who are underweight can also benefit from using an elemental diet, simply as a calorie-boosting

supplement during the exclusion phase and testing phase.
Unfortunately, elemental diets taste fairly unpleasant and are quite expensive. You
may need a prescription, so talk to your doctor. Ideally you should get an elemental diet that does not

contain sucrose (sugar).
Some items that make good snacks. Nuts, pumpkin seeds, sunflower seeds, fresh fruit and dried fruit are

all useful for times when you are away from home, or feel hungry between meals. At the outset of the

diet, use only unsulphured dried fruit –available from health-food shops. At a later stage, you can

test ordinary dried fruit (all of which is treated with sulphur preservatives – see box on p. 207).
A cooking oil, preferably one that you have not used much in the past. Use this fairly liberally, to

keep the calorie content of your diet at a reasonable level
Note that this is a very plain diet – you eat the permitted foods and absolutely nothing else. You

cannot use spices, herbs or other flavourings. Salt is allowed, but sugar is out, as are tea, coffee,

alcohol and all soft drinks. You must drink only mineral water and pure juices from permitted fruits.
Don’t use canned or packaged versions of the permitted foods. Buy raw food and cook it yourself. The

idea is to avoid food additives and other contaminants, such as those from the linings of cans.
Throughout this phase, and the next, you must be very careful not to eat too much of any one food.

Never eat any food every day, and stay away from any food that you begin to develop a real passion for

– this is always a bad sign in people with food intolerance. It is better to go a little hungry

(assuming you are not underweight to start with) rather than binge on any of the permitted foods.

Acquiring new sensitivities is all too easy.
Assuming you do have food intolerance, and you have excluded all the foods that affect you, there

should be a complete clearance of symptoms within 7-10 days. The response is usually unmistakable. A

partial or slight response is probably just a coincidence, and should be discounted, except for those

with rheumatoid arthritis (see below).
Be warned that you may feel a great deal worse before you get better. For those who do have idiopathic

food intolerance, the first 5-6 days of the diet can be very unpleasant – usually they suffer the same

symptoms as before the diet, but far more severe.
Some conditions, such as Crohn’s disease and rheumatoid arthritis, may require a longer exclusion

phase, but there is no point in continuing beyond three weeks. Bear in mind that long-term structural

damage to arthritic joints may prevent a complete recovery. A partial but sustained improvement in the

joints, accompanied by a distinct improvement in general health, suggests that food could well be

playing a part in causing the disease, and that it is worth going on to the testing phase.
Symptoms that are only intermittent, such as chronic urticaria or migraine, pose a special problem. You

need to decide, before starting the diet, how long the exclusion phase should continue in order to give

you a clear sign that your state of health is improved. A symptom diary is vital here. If, for example,

your symptom diary shows that you sometimes have a week that is symptom-free but you never get through

two weeks without an attack, then your exclusion phase should continue for two weeks.
You should only go on to the testing phase if you improve during the exclusion phase. If you do not

improve, you have excluded the possibility of food intolerance, and can give up the diet.
The testing phase
This part of the diet, which is sometimes called the reintroduction phase, takes about eight weeks. It

requires careful observation of your symptoms, and constant self-discipline about everything you eat.

You should not stop or delay the testing unless you are ill – it is vitally important to complete it as

quickly as possible.
Foods have to be reintroduced one at a time, with a space between in which symptoms can be observed. It

sounds simple, but this is where errors can easily occur.
During this phase, as well as noting your symptoms daily, you should also record absolutely everything

you eat.
For the first 2-3 weeks you should test foods that are unlikely to cause symptoms. Start by testing

fruits, vegetables and meats that you do not eat very often normally, but which you do like. If they

pass the test, you can use them to vary your diet. This will make life much easier and reduce the risk

of developing new sensitivities.
Next test foods that you do eat reasonably often, but not every day. Leave the most likely culprits –

the foods you eat very regularly, such as wheat and milk products – until you have established a safe

diet that contains at least 25 different foods. This safe and relatively varied diet should be the

backdrop against which you test staple foods.
The testing procedure changes over time, because your sensitivity may decline as the diet progresses.

During the first eight weeks, you should test one food each day, eating a normal-sized portion for

lunch or supper. A reaction to the food might occur quite soon after the meal, or some hours later. Any

symptoms that occur within the following 24 hours should be provisionally attributed to that food.
Unfortunately, bowel symptoms can sometimes take longer to develop – up to 48 hours. This can confuse

things when a new food is being tested every day.
There may also be uncertainty about intermittent conditions such as chronic urticaria. You may not be

absolutely sure that the problem really responded to the exclusion phase. If so, when the symptoms

recur during the testing phase, this may be due to a food, or it may just be coincidence.
Should there be any doubt about which food caused a particular set of symptoms, cut out all the suspect

foods for now, and retest them after a couple of weeks, using a three-day testing procedure (see

below).
When a reaction does occur to a food, stop all testing and go back to the safe diet until you feel

completely better. But don’t wait too long before resuming testing. You need to get through most of the

testing within eight weeks because, for some people, intolerance to the foods begins to fade after

that.
This does not mean that the intolerance has been ‘cured’, unfortunately. A period of eating the food

regularly will soon bring the problem back.
If you are still testing foods after eight weeks, you must change to three-day testing – eat a normal

portion of the food every day for three days, stopping only if you get symptoms. Should you have no

reaction to the food by the end of the fourth day, you can consider it safe. (But leave it out of your

diet for at least another four days.)
There are some special procedures for testing certain foods:
•    When you test wheat, even if it is quite early on, use the three-day test procedure (see

above). Reactions to wheat can be very slow. (If you have rheumatoid arthritis, you should spend a full

five days testing wheat, and eat it at least twice a day.) Don’t use bread to test wheat because this

also contains yeast and other ingredients. Use a pure wheat cereal such as Shredded Wheat – moisten it

with fruit juice if you cannot have milk. Note that some people who react to whole-wheat are sensitive

to the wheat germ, and can tolerate refined wheat, as in white bread and flour. For others only white

flour is a problem – they are usually reacting to additives in the white flour. Careful testing will

sort out these issues.
•    Test milk before cheese and butter. You may react to one but not the others. If you react to

fresh milk, wait a few weeks, then test evaporated milk. Later, you can test goat’s milk and then

sheep’s milk. Some people can tolerate these, but must be very careful not to consume too much of them.
•    You can test yeast using Marmite or yeast-based B-vitamin tablets. Do this before you test

mushrooms, •    At some point, test a canned food. This is to check for reactions to the lining

material used on cans. Choose something that contains no other ingredients or additives, such as

carrots. Test it first in a frozen or fresh form, so that you are sure you don’t have a reaction to the

food itself.
•    Throughout the testing period, continue with cooking all your own food from scratch. At a

fairly late stage in the testing, when you have tested most foods, spend three days eating packaged

food. The idea is to eat a wide range of different food additives all at once. Read the labels

carefully (see p. 172) to check that all the food ingredients are ones which you have already tested

and found safe. You are unlikely to react to these packaged foods, but if you do, you should then

conduct tests with all the individual food additives. You may need some help from a dietitian for this

(see p. 201).
Testing becomes more and more uncertain after 12 weeks. If you
have not completed it by then, reintroduce all the untested foods.
Should your symptoms come back, cut out all those foods again,
then test them individually.
What next?
For anyone who recovers during an elimination diet, and successfully identifies their problem foods, a

period of complete abstinence from those foods follows. After about a year, it is worth testing the

foods again, as the sensitivity may have subsided. (Don’t do this if you have rheumatoid arthritis –

see p. 23.)
If, after a year or two, you find that a food no longer makes you ill, don’t go back to your old ways –

remember that you must only eat the food occasionally. Once every three or four bays is a good rule of

thumb for a food to which you were previously intolerant. You might get away with having it slightly

more often than this, but never go back to eating it daily. If it starts to become your ‘favourite

food’ again – the thing you fancy more often than anything else – watch out.
Good nutrition is an important issue for anyone avoiding certain key foods. If you have cut out all

milk products, for example, you should probably be taking a calcium supplement, unless you eat a lot of

other calcium-rich foods. Ask your doctor to refer you to a dietician or nutritionist if you feel you

need help.
An elimination diet for children with eczema
Before putting your child on any kind of restrictive diet, it is vital that you talk to your doctor.

The risks of malnutrition are far higher for children, and there can be serious long-term consequences,

such as stunted growth or impaired intelligence. You must therefore have medical consent and

supervision for an elimination diet.
For young children with atopic eczema, there is rarely any need for a stringent elimination diet, such

as that described on pp. 194-7. Children are usually sensitised to only one or two commonly eaten

foods.
In the case of recently weaned infants, it is enough to simply cut out individual foods, one at a time.

Avoid each food for two weeks, while observing symptoms carefully.
For older children a simple elimination diet, with an exclusion phase which avoids just the most likely

culprits, works well. The foods that you should exclude at the outset are:
•    any food which has given a positive skin-prick test (see p. 69)
•    any food which you think may have caused digestive symptoms, such as diarrhoea, either now or

in the past
•    eggs, milk and all milk products
•    beef and chicken
•    citrus fruits (oranges, lemons etc.)
•    food additives.
If the child’s skin is no better after a week of this diet, cut out the following foods as well:
•    peanuts and other nuts
•    soya
•    fish
•    wheat and maize (corn)
•    tomatoes
•    lamb.
If there is no response after another week, food is unlikely to be contributing to the eczema.
For the testing phase, use three-day testing, as described on p. 197, if you have fewer than ten foods

to test. Use one-day testing if you have more than ten foods to test.
You should begin by testing a very small amount of the food. Wait ten minutes for any symptoms (not

just skin symptoms – the mouth or stomach may also be affected) then give a little more if nothing has

happened. Build up gradually to testing a normal portion of the food.
A more cautious approach is required for children who give positive skin-prick tests to foods, or have

a history of symptoms in the mouth or digestive tract. They are more likely to suffer severe symptoms

in the lips, mouth and throat – the type of reaction associated with food allergy. Emergency medical

treatment may be needed. You can see if there is any likelihood of a severe immediate reaction to foods

by starting with a test on the face, and then the outer lip (see box on p. 23). If nothing happens, it

is probably safe to go on to the next stage – giving the child a very small amount of the food to eat.

However, you should have medical supervision for Rare reactions
Very occasionally, atopic eczema sufferers on milk-avoidance diets develop a sensitivity reaction to

calcium supplements. There is no scientific explanation for this, but it has been very well documented

in two children. Should you encounter this problem, the answer may be some alternative natural source

of calcium: sardines or other small fish, eaten whole, are one possibility, assuming your child will

eat fish. A dietician can advise on how much is needed per day.
There has also been one well-documented report of a child reacting to mineral water. When the water she

usually drank was changed to another brand, her eczema cleared up. This is very unlikely to be a common

problem.
this procedure in the case of foods that gave positive skin tests. If your child has both severe eczema

and additional symptoms (such as nettle rash, or symptoms in the mouth or digestive tract) it may be

advisable to have medical supervision when testing all foods.
Bear in mind that atopic eczema naturally fluctuates a great deal. To observe the effects of trying out

a food, you need the child’s skin to be in a steady state. That means being absolutely consistent about

applying steroids and moisturisers, avoiding (for the period of testing) any stressful situations that

could provoke a flare-up, not exposing the skin to sudden doses of irritants or airborne allergens, and

keeping scratching under control. Be aware of other factors that could muddy the waters by provoking a

flare-up of eczema – such as teething, or a cold (see p. 44).
If certain foods are identified as provoking eczema symptoms, and you decide to cut the food from your

child’s diet, a nutritional supplement may well be needed. Ask your doctor to refer you to a

nutritionist or dietician.
Other diagnostic diets
These diets are not used by (or even known to) the majority of doctors. While some, such as the

low-nickel diet, have been subjected to rigorous scientific testing and have shown their worth, others

have not been tested scientifically. The evidence in favour of them is purely anecdotal – in other

words, doctors have used these treatments repeatedly and observed good results with some of their

patients. That is not hard science, but it is how innovations in medicine often begin.
There are few risks with any of these diets – the number of foods to be avoided is small, and you are

most unlikely to become malnourished. Your doctor should not object to you trying any of these diets,

however sceptical he or she may be about its possible benefits.
Low-nickel diet
This diet is sometimes of benefit to adults with eczema. There are various pointers which indicate that

the diet may help, as described on pp. 55-6.
Make sure that you have absolutely no contact with any nickel (e.g. in jewellery, jeans studs, watches

or hair clips) throughout this diet, and for at least two weeks before starting it.
Ideally you should also stop treatment with steroids or antihistamines a week or so before starting the

diet. This allows any improvement to be easily observed. Obviously you should get your doctor’s

permission to do this.
The diet could take anything from six weeks to six months to take full effect. Some people have a

complete clearance of their eczema, while for others there is a partial but distinct improvement.
The foods with a high nickel content, which should be avoided as far as possible, are:
•    shellfish
•    green beans and peas
•    beansprouts and lucerne sprouts
•    dry beans and lentils (pulses) of all kinds; soya protein and products containing it (e.g.

vegetarian sausages and burgers)
•    spinach and kale
•    lettuce, leeks
•    wheat bran (avoid bran cereals and other products; replace wholemeal bread with white bread, or

eat it in moderation only – you can get plenty of fibre from fruits and vegetables; do not eat

multi-grain breads at all)
•    oatmeal, millet and buckwheat
•    raspberries, prunes, pineapple, figs
•    chocolate and cocoa
•    tea from drinks dispensers (restrict intake of other tea and coffee, and don’t make them too

strong)
•    peanuts, hazelnuts, almonds and marzipan
•    liquorice
•    sunflower seeds, linseed
•    baking powder, in large amounts
•    vitamin or mineral preparations that contain nickel (check the label carefully), Nickel is also

found in drinking water, and absorbed from certain cooking utensils, so:
•    Do not use items plated with nickel (e.g. tea balls, some tea strainers, egg beaters). The

extremely shiny appearance of nickel makes these easy to recognise.
•    Do not cook acid fruits in stainless steel pans, since the acid leaches some nickel out of the

stainless steel. An enamel cooking pot is safe.
•    Minimise the amount of tinned food that you eat.
•    In the morning, run off the first litre of water from the tap, as this may contain nickel

released from the tap itself.
Several other foods and drinks seem to aggravate the skin of nickel-sensitive people, even though the

foods are not rich in nickel. These foods and drinks should also be avoided:
•    beer, wine
•    herring, mackerel, tuna
•tomatoes, carrots, onions, apples; oranges and other citrus fruits, including their juices.
Low-chromium and low-cobalt diets
Skin sensitivity to chromium or cobalt can, very occasionally, result in a tendency to react to these

same metals when consumed in food or drink (see pp. 56).
Unfortunately, both chromium and cobalt are essential for good nutrition, so avoiding them is fraught

with problems. You would need the help of a really good dietician, or a doctor with a particular

interest in nutritional problems, to guide you through a diet of this kind.
The only measure you can safely take at home is to cut down on excessive consumption of these metals,

for three weeks only, to see if this produces any improvement in your symptoms. If it does, that should

encourage you to seek expert help for a more thorough avoidance diet.
In the case of cobalt sensitivity avoid:
•    all canned and bottled beer.
In the case of chromium sensitivity avoid:
•    beer, wine and cider
•    yeast extract and yeast tablets
•    black pepper
•    calf’s liver
•    wheatgerm and wholemeal bread
•    cheese.
If you also have nickel sensitivity, avoid nickel-rich foods (see p. 199) at the same time.
Low-histamine diet
Histamine in food is mostly produced by bacterial action. The majority of people can break down any

histamine they eat, as long as the amount is not excessive (see box on p. 67).
Temporary susceptibility to histamine may accompany viral hepatitis or other liver conditions.
A permanently impaired ability to detoxify histamine is relatively unusual. When it does occur it can

result in symptoms such as chronic urticaria, migraine or recurrent headaches. A low-histamine diet may

help in these cases. All of the following should be avoided:
Very high histamine content:
•    red wine, champagne
•    tuna, sardines
•    Emmenthal and Camembert cheeses.
High histamine content:
•    beer, white wine
•    anchovies
•    Gouda, Roquefort, Stilton and all other well-matured cheeses
•    salami and other well-matured sausages, Westphalian ham
•    sauerkraut
•    spinach
•    tomato ketchup.
If you improve only partially on this diet, this may indicate that you are on the right track

(histamine is indeed the problem) but that the bacteria in your gut are undermining your efforts with

the additional histamine which they generate. You can investigate this possibility by trying a

low-carbohydrate diet, as described on p. 53.
Low-amine diet
Naturally occurring substances called amines, found in many different foods, can have a drug-like

effect on the blood vessels, making them open up a little and so increasing the blood flow. The effect

is usually small, but some people are more susceptible than others. A low-amine diet is worth trying if

you have chronic urticaria or migraines, and have not improved with other treatments. A low-amine diet

can also be useful in atopic eczema: amines in food are not a basic cause of eczema, but they can

aggravate the rash by increasing blood flow to the skin. To begin with, cut out all foods listed below:
Very high amine content:
•    all cheeses except cottage cheese
•    dark or plain chocolate
•    yeast extract (Marmite etc.), miso, tempeh, tomato paste, tandoori spice mix, stock cubes,

ready-made sauces •    cola drinks, orange juice, tomato juice
•    any dried, pickled or smoked fish
•    sausages, pies and smoked meats, beef liver, chicken skin
•    broad beans, spinach
•    sauerkraut
•    almonds.
High or moderate amine content:
•    milk chocolate
•    soy sauce
•    beer, wine and cider
•    pork, including bacon and ham, salami, chicken liver, offal
•    all fresh or tinned fish, except white fish
•    all nuts except chestnuts and cashews
•    sesame seeds, sunflower seeds
•    avocados, aubergines, mushrooms, tomatoes, broccoli, cauliflower
•    olives and olive oil
•    oranges, lemons and other citrus fruits
•    pineapples, bananas, raspberries, strawberries, pineapples, plums, grapes, dates, figs, kiwi

fruit, passion fruit.
Continue for at least three weeks, and longer if your symptoms are normally intermittent. if you

improve, you can then experiment with reintroducing small portions of foods from the second list, three

or four times a week. Gradually build up to a higher intake, but cut back if your symptoms return.
Organic diet
The objective here is to avoid pesticides, i.e. chemical sprays applied to kill fungi and insect pests.

This may be helpful for people with chemical intolerance (see p. 84).
`Chemical-free’ or ‘unsprayed’ food (crops grown without pesticides) will do just as well as 100%

organic food (which is grown without either pesticides or artificial fertilisers).
The highest intake of pesticides is from fresh fruit and vegetables, so if your budget is tight,

concentrate on buying organic or chemical-free versions of these. If you have a garden, growing some of

your own food will reduce the cost.
You can also reduce the pesticide content of ordinary fruits and vegetables by:
•    Storing them for as long as possible before using them, because the pesticides break down quite

quickly
•    Always peeling them. With difficult-to-peel items such as peaches and tomatoes, pour boiling

water over them and leave them to stand for a few minutes first, as this loosens the skin. Rinse in

cold water, then peel.
•    If peeling is not possible, washing them very well with soap or detergent, then rinsing them

thoroughly
•    Cooking them, as this drives off some of the pesticides; avoid inhaling the steam and ventilate

the kitchen well while doing this.
You should drink mineral water from a reputable source, or use a very high-quality water filter (not a

jug filter).
Additive-free diet
Food additives are occasionally the culprit in chronic urticaria (see p. 53). At the same time as

avoiding additives, people with chronic urticaria should cut out other potential culprits – alcohol,

spices and all aspirin-like drugs (see box on p. 151).
An additive-free diet may also be of value for some people with chemical intolerance (see p. 84).
In the case of children with Attention Deficit Disorder (ADD), also called Hyperkinetic Syndrome, the

role of additive-free diets is a contentious issue (see p. 81).
An additive-free diet is very healthy but quite hard work. It means making all your own food from 100%

fresh, unmodified produce (you cannot have bacon or ham, and even things like cooked chicken and

ready-to-eat salad can contain some additives; so does most restaurant food). Note that wines, beers

and other alcoholic drinks can contain many additives without declaring them on the label. (German

bottled beer is an exception here.) Baked goods sold unwrapped can also contain many additives without

declaring them.
Stop using toothpaste unless it is an additive-free brand. You can buy such toothpaste from a

health-food shop – or use sodium bicarbonate powder instead. Drink mineral water or filtered water (you

need a good-quality filter for this, not a jug filter).
Medicinal drugs can contain colourings and other additives, so you should try to get additive-free

versions. Talk to your pharmacist about this initially.
Assuming the symptoms clear up, testing can begin, but you will probably need medical help to work out

exactly which additives are at fault. It is difficult to organise these tests at home, because most

foods contain such a mixture of additives.
With chronic urticaria, there is the possibility of quite severe reactions on testing, so medical

supervision is desirable. You can undertake cautious testing with small amounts of tap water, spices

and alcohol at home, but make sure you are in a position to get emergency medical help if you need it.

Aspirin or aspirin-like drugs should not be tested at home. Life-threatening reactions are common in

sensitive individuals, and temporary avoidance can heighten your reaction.

Asthma.
Tom works for the Post Office, sorting mail on a night shift. ‘After work, I come out of the sorting office - it’s about five or six in the morning, and really cold - and when I suddenly hit the cold air, I feel as if I just can’t breathe. My chest clamps up like anything, so much that it hurts. Then, when I get in the car and put the heater on, it’s fine again.’
What Tom is describing is bronchospasm, the key event in asthma – a sudden, but reversible, tightening of the bands of muscle that surround the airways. The narrowed airways stop air from leaving the lungs at the normal speed, which means the lungs are still half-full when it’s time for the next in-breath.
Taking more air into half-full lungs produces pain and tightness in the chest, as the lungs become over-inflated. (This can be alarming, because it can seem like pain from the heart, but it is just the rib joints and chest muscles hurting as they become stretched.)
Insufficient oxygen reaches the bloodstream because there is so much stale air in the lungs, so the asthmatic also feels breathless. Meanwhile, the air being forced through the narrowed airways makes a whistling sound called wheezing.
Those are the common symptoms of asthma, but there are others:
• Coughing, rather than wheezing, is the main symptom for some people (see box on p. 40).
• Sometimes there is vomiting during an asthma attack, especially in children, because the
overexpanded lungs put a great deal of pressure on the stomach.
• A few asthmatics suffer narrowing in the trachea (the upper part of the windpipe) rather than
in the airways lower down, and therefore feel as if they are being strangled.
Bronchospasm is just the endpoint of the disease process in asthma, a process which begins with inflammation of the lining of the airways. Although the airway muscles relax when an asthma attack is over, and you therefore feel much better, the underlying inflammation of the airways remains.
Airway inflammation may be caused, or partially caused, by allergy. Among asthmatic children, allergies are detected in 80-90%.
Inflammation makes the lining of the airways swell up, which itself narrows the airways a little. The inflamed airway lining often makes more mucus than usual, in an effort to protect itself (this is basically a healthy response – mucus works like a sponge mopping up irritating dust particles so that they can be ejected by coughing – but it’s excessive in asthma). This mucus can clog up the airways even more. Finally, the inflamed airways send nerve impulses direct to the airway muscles telling them to contract.
Mucus alert
Asthmatic mucus is white or clear, and sometimes frothy. Greenish or yellowish mucus suggests an infection and should be reported to your doctor.
In severe cases of asthma, a lump of mucus can completely block an airway, leading part of the lung to collapse. It is vital to clear mucus from the lungs, and a physiotherapist can help with this.
What causes asthma?
This question can be answered at three different levels:
1 What makes someone predisposed to asthma?
2 What starts asthma off – in other words, what starts the inflammation process in the airways?
3 What triggers asthma attacks (episodes of bronchospasm)?
What makes someone predisposed to asthma?
The predisposition to asthma is partly inherited (see p. and partly a matter of lifestyle: a poor
diet makes asthma more likely (see p. 206), as does too much cleanliness (see p. 21), obesity and lack of exercise.
What starts off the inflammation?
The predisposition to asthma sets the stage, but it does not, in itself, start the inflammation of the airways. That is often begun by an allergic reaction to something in the air – such as house-dust mite or pet allergens.
Alternatively, the initiating factor could be a viral infection, especially a kind known as Respiratory

Syncytial Virus or RSV – there are epidemics of RSV every two or three years. Those predisposed to

asthma may make an abnormal kind of immune response to chest infections caused by viruses, a response

that shifts the balance of the immune system towards Th2 cells (see p. 11) and allergy-type reactions.

Although the infection is defeated by the immune system, some inflammation of the airway lining

remains.
A heavy dose of certain irritants, such as chlorine, or the substances used in spray-painting cars, can

also initiate asthma; this mainly occurs in a workplace setting, causing occupational asthma (see box

on p. 133).
What triggers asthma attacks?
Once the inflammation of the airways has begun, the airways are ‘twitchy’ –oversensitive – and the

airway muscles contract (i.e. bronchospasm occurs) at the smallest provocation. This contraction of the

muscles – an asthma attack –can be caused by irritants in the air, such as tobacco smoke, or a great

variety of other things. The possible triggers range from cold air or the scent of hyacinths, to

thunderstorms, laughter or anxiety – see p. 39 for a full list. Exposure to the allergens that started

the inflammation will also trigger an asthma attack, as will a virus (viral) infection such as a cold

or flu.
For many asthmatics, the breathing pattern is disturbed by the asthma attacks, and may remain abnormal

between attacks. Hyperventilation or ‘over-breathing’ can begin quite easily for asthmatics, and then

adds to the overall problems. It may be difficult to tell if you hyperventilate or not, because your

habitual pattern of breathing will seem normal to you, but there may be tell-tale symptoms such as

dizziness, tingling of the hands and feet, numbness and muscle cramps. For a full list of symptoms see

p. 227.
Mind power
The muscle of the airways is the kind of muscle over which we have no conscious control, like that of

the heart. It is known as involuntary muscle, whereas muscles in the arms and legs, which contract or

relax when we tell them to, are called voluntary muscles. Studies with biofeedback have shown that

asthmatics may, with training, gain some degree of control over these involuntary muscles. Experienced

yoga practitioners are able to influence certain involuntary muscles, including those in the airways.
There are also various ways in which the mind, or a person’s social and emotional situation, can make

asthma worse (see p. 234) but the damaging idea that it is an entirely ‘psychological’ disease is now

discounted.
Allergens and irritants
Understanding the difference between allergens and irritants is important for asthmatics. Allergens are

specific — either pollen is an allergen for you or it isn’t, depending on how your immune system reacts

to it. They are also a basic cause of asthma — they start it off.
Irritants, on the other hand, are non-specific: they affect every asthmatic if sufficiently

concentrated, causing bronchospasm by aggravating the airway lining. And, at the levels usually

encountered, they only cause trouble because the inflammation of the airways has already occurred.

Irritants include cigarette smoke, other smoke and some industrial fumes, ozone (see p. 130), sulphur

dioxide (given off by some foods and drinks — see box on p. 207), fly spray, air freshener and other

aerosols.
Diagnosis
There are four separate aspects to diagnosis:
1 Is this really asthma or something else entirely?
2 Is it combined with other diseases, and how are they affecting the asthma?
3 What is the basic cause of the inflammation in the airways, and can this be avoided?
4 What sort of factors trigger the asthma attacks?
You may not get this full diagnostic programme, but you can probably help in finding answers to some of

the questions.
Is this really asthma or something else entirely?
There are no tests that can diagnose asthma with complete certainty, but the average case of adult

asthma is pretty easy to spot, and the same is true for children over five. It is also true, however,

that some patients now described as asthmatic would have been given a different diagnosis (e.g. wheezy

bronchitis) thirty years ago. To some extent, this is because asthma was under-diagnosed in the past:

doctors were hesitant about giving a diagnosis of asthma, because of the supposed overtones of

psychosomatic disease. Sweeping away that stigma has been of immense value, but certain patients

(especially young children) may now get diagnosed as asthmatic without sufficient evidence. However,

there are also many instances of asthma being missed.
There are two tests that should be carried out before you are given a diagnosis of asthma:
1 Peak flow is the top speed of the outgoing air from your lungs, usually measured with a simple

portable machine called a peak-flow meter. Because of the narrowed airways, asthmatics have a lower

peak flow than normal.
2 The reversibility test depends on measuring peak flow before and after inhaling a beta-2 reliever

drug which relaxes the airway muscles (see p. 152). If the drug improves peak flow by more than 15%,

this strongly suggests asthma.
Asthma may be difficult to diagnose in certain situations:
• In babies, who often wheeze, especially when they have colds or chest infections. This

generally clears up later and does not automatically develop into asthma. There is great controversy

about whether wheezy babies should be labelled ‘asthmatic’ or not, and how bad the wheezing should be

before they are given asthma drugs. Views on this vary, so you may want to see a different doctor for a

second opinion. For older children who wheeze only when they get chest infections, most doctors feel it

is valuable to use asthma drugs – such treatment does not ‘turn wheezing into asthma’
as is sometimes claimed. (There are several things you can do to minimise the chance of early wheezing

turning into asthma later – see pp. 244-9.)
• When the main symptom is coughing (see box on p. 40).
• When asthma occurs only at night. In some asthmatics, even intensive testing reveals no

abnormality in the airways during the day. The only way to diagnose the condition is to use a peak-flow

meter at home, morning and evening.
• When there is a sudden one-off asthma attack in response to a powerful allergen load. This

sometimes happens to hayfever sufferers at the height of the pollen season (especially during

thunderstorms). Some doctors will want to start asthma drugs immediately, but it may be better to get

the hayfever well controlled with antihistamines and see what happens. Often there are no further

asthma attacks.
Then there are conditions that can be mistaken for asthma:
• In children, an inhaled object – such as a nut or part of a toy – becoming stuck in the

airways. In babies it can also be inhalation of milk droplets; if so, the ‘asthma’ comes on mainly

after feeding.
• Post-nasal drip (see p. 29)
• Heiner’s Syndrome – (see p. 72)
• Bronchiolitis: a viral infection (generally caused by RSV –see p. 37) which affects the small

airways (the bronchioles) of babies and toddlers. Unlike asthma, it usually produces fever.
• Gastro-oesophageal reflux (GER), or the rising of acid from the stomach into the oesophagus.

(This is commonly called heartburn, after its most typical symptom, but you can suffer from GER without

having heartburn.) GER can aggravate existing asthma, and it can also be an asthma mimic. Babies,

children and adults can all suffer from this problem. There will usually be clues such as symptoms that

come on at night after a late supper, or whenever lying down.
• Hyperventilation (see p. 227) in non-asthmatics can be misdiagnosed as asthma if it causes

breathlessness.
• Aspergillosis (see box on p. 18)
• Problems with the vocal cords. Habitually contracting the vocal cords on the in-breath makes a

loud wheezing sound and can cause breathlessness. This problem can mimic asthma, but it also affects

those who really are asthmatic. The cause may be psychological.
• Low-level carbon monoxide poisoning, generally from gas fires, which can cause breathlessness

and fatigue.
• Bronchlectasis: stretching and damage to the airways caused by diseases caught in childhood,

such as pneumonia or whooping cough. This causes lifelong breathlessness.
Is it combined with other diseases, and how are they affecting the asthma?
Any allergic problems in the nose will contribute to asthmatic symptoms in the lungs, because there are

nerve-connections between the two. Long-term sinusitis can also make matters worse. Optimum treatment

for the nasal and sinus symptoms (see pp. 28-35) will help considerably with the asthma.
One unlikely source of asthmatic symptoms has only recently been recognised: allergies can develop to

the fungi causing athlete’s foot, or other diseases (see pp. 16-17).
GER (see p. 38) can contribute substantially to asthma. In some people, the reflux causes no obvious

symptoms, apart from worsening the asthma; medical tests can show that reflux is occurring. Your doctor

can advise on this, and on treatment.
For older people, especially veteran smokers, asthma may be part of a larger picture of inflammation

and damage to the air sacs of the lung (emphysema) and/or to the airways (bronchitis). This mosaic of

problems is known as chronic obstructive pulmonary disease (COPD). It may be difficult to tell if there

is asthma present, or how much it is contributing to the overall problem. Since many patients with COPD

are helped by asthma drugs, and trying out the drugs does no harm, doctors often prescribe them just to

see what happens.
What is the basic cause of airway inflammation? Skin-prick tests are usually needed here, to check for

allergic reactions. It may be difficult to get these in Britain, where there is a shortage of

allergists (see p. 89).
Simple detective work may pinpoint allergens without the need for tests. The likely suspects are all

airborne allergens – see p. 28. Remember that the reaction does not generally start as soon as exposure

to the allergen begins: there is a time-lag. So a new dog or cat, or an allergen encountered at work,

may cause no trouble for the first year or two.
Some irritants can also be a basic cause of asthma, but only if encountered in high doses, which

usually occur in the workplace. These are called asthmagens (see box on p. 133).
In all cases, removing the allergen or irritant from the airways should be a top priority. The sooner

you can end the exposure, the more likely you are to shake off the asthma, rather than have it for

ever. Once the inflammation of the airways is firmly established, it just fuels itself – so act

quickly.
In a minority of cases, food sensitivity is the initiating cause of asthma. The reaction to food is

delayed, so the link will not be obvious. Skin-prick tests for the culprit food are usually negative,

so an elimination diet (see p. 194) is needed to diagnose this problem and identify the food concerned.

Those most likely to benefit are brittle asthmatics (those most severely affected) – as many as 60%

have a food sensitivity. There are various other clues that food could be a factor (see p. 69).
When asthma begins in adulthood, there may be no clear initiating cause – it is just a question of

long-term damage and irritation to the airways. But there can be allergens playing a part, so it is

worth investigating this possibility.
What sort of factors trigger the asthma attacks?
Most asthmatics will recognise one or more of these as triggers:
• cold or dry air
• strong smells including perfume and fragrant flowers
• irritants in the air (such as cigarette smoke and other indoor pollutants, traffic fumes,

industrial pollutants); indoor pollution is often the worst, especially if you have a gas cooker

without adequate ventilation, so there is a lot you can do to improve the air you breathe (see pp.

128-30)
• sulphur dioxide given off by preservatives used in some food and drink (see box on p. 207)
• weather conditions, particularly thunderstorms
• laughing, sighing, yawning, coughing or any other altered breathing pattern
• stress or anxiety
• strong emotions such as fear, anger or excitement
• situations or people that evoke unpleasant memories –including traumatic childhood memories;

sometimes psychotherapy is needed to sort out such problems (see p. 233)
• exercise (because breathing hard dries out the airways)
• the allergens responsible for the asthma, e.g. cat allergen
• colds, flu and chest infections.
Recording your symptoms day-by-day should help to identify the triggers that are most powerful for you.

Generally speaking, such triggers should be avoided, but this is not the case for exercise which does

much more good than harm, in the long run – without exercise, your asthma will get far worse (see p.

41).
Take care with aspirin
Aspirin sensitivity can develop unexpectedly in asthmatics, especially those with allergic rhinitis

and/or nasal polyps (see box on p. 28). It can produce a severe, even fatal, asthma attack in someone

who has previously been able to take aspirin (see p. 151).
Treatment
The first and most important aspect of asthma is environmental control – to try to minimise contact

with allergens and irritants. If you are asthmatic and you smoke, you must stop, because this will only

make matters worse by stoking up the inflammation. Any other smokers in the family should accept that

from now on this is an outdoor activity.
One of the aims of good asthma treatment is to calm the airways down, so that they are less sensitive

and ‘twitchy’. This means tackling the inflammation. You can do this with preventer drugs such as

steroids or cromoglycate (see p. 157), or with the new anti - leu kotriene drugs (see p. 159), or you

can simply remove the basic cause of the trouble, if it is a domestic allergen source, such as a cat, a

dog or house-dust mites.
Treating associated diseases such as sinusitis, hayfever, perennial allergic rhinifis, gastroesophageal

reflux (GER – see p. 38) and athlete’s foot (where this is adding to the symptoms – see p. 16) can also

help in reducing the airway inflammation. Eating a better diet may make a further contribution to

calming the airways down (see p. 206).
The second strand of treatment is to deal with bronchospasm (contraction of the airway muscles) when it

occurs. This is done with reliever drugs such as Ventolin and Atrovent (see p. 152). Note that these

only relieve the symptoms of an asthma attack, and do not address the underlying problem of

inflammation. What is more, if used too frequently (more than once a day) they may increase the risk of

a fatal or near-fatal asthma attack (see p. 153).
At one time, reliever drugs were the mainstay of asthma treatment, and were perceived as entirely safe,

while preventer drugs such as steroids were only given to those with severe asthma. All this has

changed, and most asthmatics, other than those with very infrequent attacks, are now given a

pre-venter. If your drug regime has not been reviewed for some time, make an appointment with your

doctor and check that you are getting the best of the modern treatments.
Drug treatment of asthma is not something you can just hand over to the doctor – it requires a lot of

personal decision - making. If you usually get worse when you have a cold, for example, you need to
Just a cough?
For some, coughing is the main symptom of asthma. Known as cough-variant asthma, this is not always

diagnosed correctly, especially in children. For children with recurrent coughing (two or more episodes

per year of coughing without a cold) it may be a long time before the doctor considers asthma. But

other doctors may diagnose a coughing child as `asthmatic’ all too readily, without doing enough tests.

The important point is that asthma involves episodes of bronchospasm – contraction of the airway

muscles. Without this it is not asthma. Bronchospasm can be detected by medical tests such as peak-flow

readings. Wheezing is one possible symptom of bronchospasm, but coughing is another.
If there is only coughing as a symptom, and never any wheezing, this is probably not asthma. Among

children with this pattern of symptoms, allergies are unlikely to be involved. The cause of such

coughing may be:
• in children, the effects of parental smoking
• in those with perennial allergic rhinitis (see pp. 28-9) mucus from the nose running into the

lungs. This is called post-nasal drip and produces a persistent cough.
• in the middle-aged, eosinophilic bronchitis. This is caused by an influx of eosinophils (see p.

19) into the airway lining, causing inflammation. Allergies do not seem to play a part (it is no more

common in atopics than anyone else) and the airway muscles do not contract abnormally. Treatment is

with inhaled steroids.
• in atopics (those prone to allergies), a condition sometimes called atopic cough. It involves

eosinophils congregating in the trachea (windpipe) and bronchi, but not in the lower airways. There is

inflammation but no airway narrowing. Very little is known about this disease at present; it may or may

not involve allergies. Again, inhaled steroids are effective.
• for a few people, habitual coughing. This is usually an expression of some underlying emotional

difficulty and responds to psychological treatments. The cough often has a honking or barking sound.
Any of these can be misdiagnosed as asthma. For patients with eosinophilic bronchitis or atopic cough,

this is no tragedy as they will probably get the right treatment (inhaled steroids) anyway. But if more

exact diagnostic criteria are being used (e.g. a reversibility test – see p. 38) such patients will not

be classed as asthmatic – this is more of a problem because they may not get appropriate treatment.
increase your dose of preventer as soon as a cold appears, to stop airway inflammation before it

starts. You also need to know when an asthma attack is serious enough to warrant calling an ambulance.

A management plan, worked out with your doctor, is a useful aid (see p. 96). Using a peak-flow meter,

night and morning, to monitor your asthma will also be valuable (see p. 97).
The third strand of asthma treatment is to deal with associated problems:
• Panicky reactions during asthma attacks –which make matters infinitely worse – can be dealt

with by meditation, yoga, relaxation techniques or martial arts training (see p. 222).
• Hyperventilation, which plays a much larger role in asthma than previously suspected, can be

tackled by a variety of methods (see p. 228).
• The distortions of the rib-cage that develop in severe asthma can be treated with osteopathy.
• Losing weight, if you are very heavy, will help ease the burden on your breathing.
Exercise and asthma
Exercise-induced asthma is best tackled, paradoxically, by taking exercise. As your fitness improves,

you don’t pant so hard when exercising, so your airways dry out much less. Countless asthmatics will

tell you that once you overcome the first hurdle – of wheezing the minute you start to exercise –

things get a great deal easier. You will need reliever drugs, and possibly extra preventer, to help you

over this hurdle, but it’s worth it. Warming up with a few sharp sprints, separated by a rest period,

will also help. (If you get an asthma attack while exercising, however, you should always stop –

carrying on regardless can be fatal – literally. Always have your reliever inhaler with you when you

exercise and use it if you get an attack.)
Swimming is an excellent starting point for unfit asthmatics, because the moist air prevents the

airways from drying out. Swim outdoors if you can, since chlorine can be an irritant.
Once you are fitter, regular strenuous exercise makes the breathing muscles stronger, which is of great

benefit – this can also be achieved with special exercises (see p. 231).
Don’t underestimate asthma
Asthma can be fatal, so never take it too lightly. If you often wake up in the night with asthma, you

cannot keep up with most other people your age, or are frequently breathless when climbing stairs or

walking uphill, then your asthma is not under control. The same is true if you need your reliever

inhaler more than once a day, or frequently need steroid tablets. Review your treatment with your

doctor because you probably need more preventive treatment such as inhaled steroids (see p. 157) or

anti-leukotriene drugs (see p. 149).
Recognising an asthma attack and knowing when to call for help, or go to the hospital, is also crucial

(see p. 100). Remember that fatal asthma attacks often come on very quickly – half those who die do so

within two hours of the attack starting, and a quarter die within 30 minutes. Those who die are

generally people who have neglected their preventer medication, or have been exposed to very high

levels of allergens.
There is a major organisation involved in asthma prevention, by the name of Asthma UK. They work together with people with asthma, health professionals and researchers, to develop and share expertise to help people increase their understanding of asthma, and asthma prevention, allowing them to voice their concerns to the people who matter and reduce the effect of it on their lives. They are the only charity dedicated to asthma prevention by improving the health and well-being of people with asthma and are funded by voluntary donations, indeed they are responsible for nearly £3m of asthma research each year for the cause of asthma prevention.

A form of asthma prevention can be in the improvements in environmental quality to benefit everyone in the school building because pollutants have a universally negative effect. For example, for the benefit of the students, schools should undertake extensive building repairs, painting, cleaning, and extermination during long vacations. They should replace plastic furniture and carpeting, which often emit pollutants in the form of noxious gases. For further asthma prevention, they should limit use of cleaning supplies and equipment that emit toxic fumes and strong odours which again are pollutants, and require good ventilation when they are used. They should have the entire building (particularly the heating and ventilation system) cleaned regularly to eliminate dust mites, mildew, animal dander, feathers, cockroaches, and other possible asthma and allergy triggers, and make sure that leaks of water and plaster dust are stopped and quickly cleaned up. Additionally the can help in asthma prevention by regularly monitoring the air quality of schools, especially those in sealed buildings and try to increase the ventilation so that pollutants can escape. All this can help with asthma prevention. So whilst schools may not be able to eliminate other pollutants, such as chalk dust, they can, as an act of asthma prevention, find out which of them are triggers for particular students and try to limit the student’s exposure to them. Further, sensitive scheduling can keep students with specific sensitivities away from certain art supplies and animals, which may enhance the education of some students but sicken students with asthma.

As an asthma prevention in Scandinavia, cross-country skiers sometimes wear breathing masks which store the heat and moisture from the air they breathe out and then return it to the air they breathe in. This is helpful in avoiding exercise-induced asthma. Good control of your asthma, whether by breathing in a ‘preventer’ treatment or by avoiding causes of asthma such as house dust mites and pets can have a tremendously helpful effect on exercise-induced asthma. Reliever inhalers can be tremendously helpful in asthma prevention if you use them just before you exercise. This applies especially to the so-called ‘beta-2 stimulants’ such as salbutamol (albuterol) or terbutaline. The benefit should last for hours. Long-acting reliever inhalers are also very helpful; they just work for longer. If you are a competitive athlete or sportsman, you may be concerned about disqualification because you use drugs. The good news is that all the ordinary asthma medicines, used in the medically recommended way and dosage, are acceptable to sporting bodies provided you use them correctly for asthma. The wise thing is to check with your sports authority or sports doctor. Asthma prevention is good asthma management!
There are oral asthma medications that an individual can take to control their asthma, inhaled at the onset of an asthma attack. People with asthma can carry a peak flow meter; a hand-held tool for measuring their air flow to determine whether an attack is imminent, thus requiring their asthma medications. With help from medical providers and age-appropriate printed materials, children can learn to monitor their asthma and self-medicate with their asthma medications. Taking such control of their asthma medications not only decreases its symptoms, but also promotes the children’s feelings of self-confidence, with the management of their asthma and its medications.

There are dozens of asthma medications available in the UK; the most frequently prescribed of these medications being: Ventolin; Bricanyl; Becodite; Pulmicort; Intal and Tilade. The first 2 asthma medications are essentially relievers, whilst the others are preventers. The preventer drugs are taken by an inhaled route and must be taken regularly to gain maximum effect. They belong to either the steroid or anti-inflammatory groups of asthma medications. The reliever drugs do not need to be taken as often; indeed there is evidence to support that these medications are more effective when they are taken only occasionally. Naturally there will be a concern about side effects, but in the main, asthma medications are safe and free from problems.

One such treatment which can have side effects is a steroid called prednisolone; which is taken by tablet form. These asthma medications dampen down and reduces inflammation, swelling and phlegm. There is a soluble form of these medications called Prednesol, which is useful for children and people who struggle to swallow tablets. If used in short courses there should be no risks at all; it is only when these asthma medications are prescribed over a period of years that certain side effects can occur. These include skin changes, thinning of the bones, increased blood pressure, indigestion, ulcers and the development of diabetes. Once again the emphasis is on serious long term prescriptions of these asthma medications and a brief course has no history of causing any of the above side effects.

Asthma is not an allergy as such, but there are asthma triggers, which can be caused by an allergic reaction to any number of incidents. If you have asthma, your air passages are irritable. This means things which are harmless to other people may be asthma triggers to an asthma sufferer. Various asthma triggers include: (i) Emotional stress - people with asthma often say their asthma gets worse if they are upset. (ii) Cold air - if you move from warm indoor air to cold air outdoors it can affect the air passeges. (iii) Pollution, in particular tobacco smoke - e.g. in a pub, can be one of the more common asthma triggers. (iv) Grass pollen - particularly when exposed to a recently mown lawn. (v) House dust mites - often attracted by central heating. (vii) Pet fur - especially during the malting season can affect the air passeges. (viii) Exercise - can provoke narrowing of the air passages. (ix) Infections of the lining of the breathing passages - e.g. colds and ‘flu. (x) Some drugs - especially medicines called beta blockers used for high blood pressure or heart disease have been known to be asthma triggers. (xi) Indigestion - also called gastro-oesophageal reflux, with stomach acid coming up into your gullet. (xii) Laughing - so don’t laugh! (Only joking, but it can happen). All the above reflect the irritability of the air passages in asthma, even if some of them do so in somewhat different ways, they all can be asthma triggers.

There have been significant changes in air quality over the past few decades. Pollution, from the burning of coal, which resulted in emissions of sulphur dioxide and particulate matter has decreased considerably; however, the frequency of peaks of traffic related pollution and the geographical extent of it have probably increased. Episodes of pollution from secondary pollutants, notably ozone, produced by photochemical oxidation, have also increased and this is one of the chief asthma triggers. Moreover, there have also been changes in people’s diet, lifestyle, and in homes and other indoor environments. For example, homes have tended to become warmer and, in this and other ways, much more appealing to cohabitation by dust mites, a real enemy of asthma sufferers. All these can act as asthma triggers. Cinemas and theatres can also surprisingly act as asthma triggers for some people. Research carried out recently found low levels of bacteria and moulds on carpets and seats, but high concentrations of cat allergens; presumably brought in on the clothes of members of the audience. Maybe get a DVD next time!

Allergies and
inheritance
WHY IT RUNS IN
FAMILIES
`My father had asthma as a child, and his sister had it too. In fact she died from it. My mother has never had any allergies, but one of her brothers had terrible hayfever all his life. Out of us four, only my brother Peter is completely allergy-free. I had bad eczema when I was small, as did my sister. So when our son developed eczema, and then asthma, and an allergy to house-dust mite which made his nose run all the time, I wasn’t entirely surprised.’ What Janet’ is describing is a good example of an atopic family — one where classical allergies, of one kind or another, affect several family members. The members of such a family are called atopics.
Atopics have an underlying tendency to allergy which, with luck, may never be expressed. But if they are unlucky, the tendency will lead to allergies, which can settle on the skin (atopic eczema), the nose (hayfever or perennial allergic rhinitis), the airways (asthma) or the mouth and digestive tract (food allergy). These diseases, which recur down the generations in atopic families like Janey’s, are known as the classical allergic diseases.
The atopic tendency is coded into our DNA –in the genes that are passed from parent to child. There are also other genes that make asthma more likely to develop, and these can work in concert with the allergy-promoting genes to produce asthma in a child. And there are probably genes for dry skin, which contribute to atopic eczema.
Genes alone are not enough, however. Environment (which means, in medical terms, everything external that affects an individual,
including diseases, diet, air, allergens such as dust mite or pollen, and even medical treatment) also plays a large part in promoting allergic reactions. In other words, genes and the external world interact to produce allergic disease. What happens in the months and years immediately after birth seems to be a crucial element.
This helps to explain why allergies are on the increase even though we are, genetically speaking, not so different from our grandparents or great-grandparents. It is also a cause for optimism, since it means we can largely reverse the trend in coming generations. All we have to do is adjust the environment, especially for newborns and young children. Luckily, most of the problem factors are ones over which we have personal control, such as smoking by parents, diet, infant feeding, hygiene (less is better), antibiotic treatment, house design and furnishings Generally speaking, inherited traits such as height or skin colour are governed, not by a single gene with a large effect, but by a great many genes each with a small effect. This is called multi-gene inheritance. The many small effects add up to produce the final outcome. Atopy is probably inherited in a similar way, which would explain why some people have a very strong tendency to allergies (they have lots of the wrong genes) while other people have only a mild tendency (they have just a few).
Current estimates hold that at least twenty different genes are involved in determining atopy. This means that no two atopic individuals are going to be quite the same, because each will have a different combination of the possible variants on these twenty genes. In the words of Dr Vincent Beltrani, of Columbia University, New York, ‘it is not surprising that, as a result of all the possible genetic combinations and permutations, each atopic individual possesses a unique “allergic fingerprint” and that not all atopic individuals have identical findings’.
Multi-gene inheritance has another important effect, in terms of predicting who will develop allergies. The genetic risks from the two parents add up, so if both parents have allergies themselves or come from atopic families, the risks of the child developing allergies are much higher than if only one parent is atopic. The actual figures are uncertain because the results vary considerably from one study to another. If one parent is atopic, the risk can range from 20% to 58%, whereas if both parents are atopic, the risk ranges from 50% to 80% or even more.
Note that these are just risks: there are no certainties here because the actual mix of genes that a child receives is a selection – half of the mother’s genes and half of the father’s. There’s no saying which half a child gets, because this is a random selection process, similar to the shuffling and dealing of playing cards. Luck plays a big part.
Naturally enough, both atopic parents and their doctors have asked whether there is any test that could assess the number of pro-allergy genes in a newborn and so predict the chances of allergy developing in particular children. That would allow more stringent anti-allergy measures  to be taken for the children most at risk.
Various tests have been tried, and one does work, to a limited extent. It involves measuring the level of the allergy antibody, IgE, in a blood sample taken from the umbilical cord just after birth. Very high levels of IgE give some indication of the chances of allergies developing later, but the accuracy of the prediction is, unfortunately, not that good when the test is carried out in atopic families. The test doesn’t reveal much more than is already known – that the baby has atopic parents.
This same test, when carried out on newborns who are not from atopic families, sometimes gives a much more useful and accurate result. In one study, 75% of those babies with high levels of cord-blood IgE developed allergies a few years later, compared to only 6% of those with low levels. Unfortunately, the test does not always give such impressive results, and some disappointing studies have led doctors to conclude that it is not worthwhile as a standard test for all newborns.
This finding of high IgE in children from non-atopic families highlights an important point: pro-allergy genes are everywhere. A lot of healthy people have them, but at levels which do not cause any symptoms – yet. This explains why, with the allergy epidemic, many new allergy sufferers are coming from families never affected by allergy before. As our lifestyle becomes more pro-allergy, a baby needs fewer of the pro-allergy genes to grow into an allergic individual.
Other forms of sensitivity
The multi-gene inheritance of classical allergy is very different from the inheritance of diseases such as primary lactase deficiency  where there is a single gene that is at fault. Generally, speaking, all metabolic abnormalities are inherited in this straightforward way, so they are an all-or-nothing affair: one child in the family gets the defective gene while another does not. No environmental triggers are needed to activate the defect.
In the case of food intolerance, if minor metabolic abnormalities play a part, as they may do for some sufferers, then there could be inheritance of the defect, but this will not necessarily lead to symptoms unless other intolerance-promoting factors (such as disturbed gut flora) are present. Those who suffer from both food intolerance and chemical intolerance (also called chemical sensitivity) are the most likely to have metabolic abnormalities, and it is interesting that such problems do sometimes affect several members of the same family. (Doctors who are sceptical about such diseases will dismiss this as simply ‘learned illness behaviour’ among family members, a theory that is difficult to test without a lot of expensive research.)
Inheritance plays a part in several other forms of sensitivity. It is very important, for example, in coeliac disease and dermatitis herpetiformis , which both stem from the same genetic feature. They are only expressed when wheat is eaten but the timing is important here – introducing wheat into a child’s diet later, rather than during the first year of life, seems less likely to provoke the disease. When coeliac disease comes on in adult life, it suggests that some other environmental trigger was needed, in addition to eating wheat, to start off the disease process.