Posts Tagged ‘culprit’

Allergens and irritants at work
Some workplaces have very high concentrations of allergens in the air, especially if proper safety procedures are not being followed. Occupational allergies can begin with symptoms in the nose, such as sneezing, blockage or constant streaming (allergic rhinitis). You may also suffer with itchy or watery eyes (conjunctivitis), a cough, sweating and a feverish feeling. Alternatively, direct contact with the allergen can produce a skin rash (dermatitis) or itchiness and swelling (contact urticaria/nettle rash and angioedema).
If you work somewhere with an allergy risk (see pp. 133-4), be vigilant for such symptoms and see your doctor immediately. These symptoms can be the forerunners of occupational asthma, which is a serious and potentially irreversible problem. Some allergens, such as latex, can even produce anaphylactic shock (a life-threatening allergic collapse).
Skin-prick tests (see p. 91) can show if you have an allergy to a substance encountered at work.
Acting promptly gives you the best possible chance of recovery and is vital if you have occupational asthma. Only if exposure to the allergen stops promptly do you have a good chance of shaking off the asthma. See your doctor as soon as possible and ask for a referral to a chest specialist, so that a definite diagnosis can be made. This is essential if you are going to make a claim for compensation.
Far too many people with occupational asthma are just sent off with an inhaler when they first see their doctor. By delaying the moment when work is identified as the source of the problem, and the exposure to the allergen is stopped, drug treatment can turn occupational asthma into a disabling lifelong problem. Although drugs can be helpful in speeding your recovery once exposure to the allergen
Latex allergy
Sensitisation to latex usually occurs at work (see pp. 133-4), or as a result of having many surgical operations. But latex allergy sometimes occurs in allergy-prone people even though they don’t work in a high-risk job and haven’t had many operations. Some doctors think that if a child with severe allergies needs surgery, this should be done in latex-free conditions, even though the child has no allergy to latex, because of the risk that the operation will sensitise.
Latex can cause either contact dermatitis (see p. 55) or a Type I allergy, whose symptoms can include urticaria, asthma and anaphylaxis. Latex allergy often goes undiagnosed. Once sensitised, you may react to balloons, elastic bands, condoms and household gloves. Latex in the air,
due to powdered latex gloves being used, can be a hazard for someone who is highly sensitive, as can latex traces in food (see box on p. 175). Medical treatment may be problematic (see p. 98 and box on p. 249). Cross-reactions to certain foods can occur (see p. 15 and p. 51).
For those avoiding latex, there are non-latex gloves (see p. 57), and non-latex condoms. Immunotherapy (see pp. 164-9) may be useful in severe cases: it can reduce sensitivity and eliminate cross-reactions to foods.
Other hazards
This article (pp. 132-5) deals mainly with allergens at work, that is, substances which provoke classical allergies (Type I reactions). In addition, there are skin irritants and antigens in workplaces which can provoke contact dermatitis (see p. 56) or contact urticaria (see p.50).
Some of the most dangerous workplace substances are those that bring on asthma but are not allergens. These are usually called low-molecular-weight asthmagens. The most notorious of these are platinum salts, isocyanates (used in cement, in the manufacture of foam, plastics and varnishes, and for spray-painting cars, aeroplanes and boats), colophony (used as a solder in electronics), glutaraldehyde (used in hospitals for sterilisation procedures), and persulphate (used in hairdressing). Powerful respiratory equipment, supplying air from outside the area (see p. 135) is needed if you work with some of these substances, e.g. isocyanates for spray-painting cars.
has ended, they should not be seen as a way of allowing you to go on working with the offending allergen or asthmagen.
If it seems plausible that your allergies or your asthma are related to your work, your doctor should be able to give you a sickness certificate, so that you can have some time away from the workplace, to see if you recover. The medical service at your workplace may be better at diagnosing occupational asthma than your own doctor, but be cautious. In some workplaces they do operate as they should and offer genuinely confidential treatment. But there have also been cases of information being passed to the management, and workers with the early signs of occupational allergies and/or asthma being dismissed on a pretext, or made redundant, to avoid a possible compensation claim. Most occupational health services claim to be independent, but they actually have to earn the trust of the workforce. Before you make any move, ask your colleagues for their views, especially those who have worked there for many years.
Choosing a job
If you have any tendency to allergies, or come from an allergy-prone family, you should be very choosy about where you work. Try to avoid workplaces where there is heavy exposure to allergens, especially airborne allergens which can provoke asthma:
• Bakeries and flour mills, where the allergens concerned may be wheat proteins in the flour, or enzymes added to the flour mix. These allergies can take years to begin.
• Other food-processing works, particularly those dealing with tea, soyabeans, other beans (e.g. gram flour), shellfish and fish (especially if automated gutting machines are used without adequate ventilation). Food preparation and sandwich-making can cause contact urticaria, if there is prolonged contact with a particular foodstuff (e.g. tomatoes).
• Farms, docks and cotton mills – or any other workplace generating dust from plant products. On farms, it is the dust from grain and hay that is often responsible, although mould spores (see p. 121) can also be the culprit. Allergies to mites (found in hay, grain and flour) sometimes occur and eczema is the most common symptom – often called simply ‘grain itch’.
• Saw mills and joineries, because of the wood dust, especially that from hardwoods and from red cedar (Thuja plicata).
• Paper recycling plants, if there is a lot of paper dust in the air.
• Detergent and pharmaceutical factories handling enzymes – these are added to ‘biological’ washing powders and are potential allergens. The risks are less these days, as the enzymes are in granule form rather than powder.
• Factories processing natural products such as psyllium or ispaghula, which are used as laxatives. Anyone who has been sensitised should avoid taking medicines containing the offending substance in the future, because these can sometimes provoke a dangerous anaphylactic reaction.
• Hospitals, clinics and dental surgeries, mainly due to latex rubber, used in gloves and equipment. Although nursing staff and surgeons are most susceptible, other staff including hospital administrative workers can occasionally be affected. Fears about the spread of the HIV virus has led to a huge increase in the use of latex gloves in medicine and dentistry, and a consequent epidemic of latex allergy. The main problem is with powdered latex gloves, which release 15,000 times as much allergen into the air as unpowdered gloves. Unpowdered, low-allergen gloves greatly reduce the risk of latex allergy developing, and non-latex gloves are even better. There are moves to ban the import of powdered latex gloves into Britain. They are already being phased out in hospitals and other medical facilities, but progress is slow in some areas.
• Other workplaces where powdered latex gloves are used, including
Making the workplace safe for everyone
Note that these choices about employment are for the individual employees to make for their own protection - an employer cannot refuse to take anyone on because they have allergies or come from an atopic (allergy-prone) family.
The reasoning behind this is that the workplace should be safe for everyone, as far as possible. As many as one in three of the population may be susceptible to allergies, and it is clearly wrong to bar all such people from major industries. Current thinking, in most countries, is that the focus should be on getting allergens and asthmagens out of the air, not keeping the more vulnerable workers out of the workplace.
hairdressers, dental surgeries, pathology laboratories and police stations. Construction workers wearing rubber gloves are also at risk. Someone who has been sensitised by powdered latex gloves may then react to other items (see box on p.132). Those severely affected can have great problems in daily life and with medical treatment, so anyone with a strong tendency to allergy should strenuously avoid becoming sensitised.
• Factories making or using rubber items may also expose workers to the risk of latex allergy. Anything made by the ‘dipping method’ (e.g. balloons, condoms, elastic bands and gloves) is highly allergenic. Moulded rubber items, such as tyres, are much less of a problem. Neoprene and other synthetic rubber items are not allergenic.
• Chiropody and podiatry clinics, where there is a risk of allergic reactions to the fungus that causes athlete’s foot. It is inhaled on skin flakes from the patients’ feet.
• Laboratories and other workplaces where animals are kept. In the case of mice, rats and other rodents, the allergen is found in the animals’ urine, and becomes airborne as the urine dries. Insects and spiders (e.g, those reared for biological pest control), are also allergenic due to small airborne particles from their bodies. Those working closely with bees (either honeybees or bumblebees, now reared for pollinating glasshouse crops) are liable to be stung frequently, and this can lead to sting allergy (see pp. 60-61).
• Hairdressing salons, where many different items are used that are potentially allergenic, including latex gloves (see above), permanent-wave solutions and henna. The risks of contact dermatitis are also high (see p. 55).
• Greenhouses, where the enclosed conditions can lead to high levels of allergens from plants, moulds and insect pests. There may also be exposure to pesticide sprays or their residues, which can greatly aggravate any underlying tendency to allergies.
If you have ever suffered from atopic eczema, work situations that can bring on contact dermatitis should also be avoided (see p. 55).
Taking a risky job
If circumstances force you to take a job with an allergy risk, observe all the safety procedures that are in place, and where you have the option of turning on extractor fans, wearing protective gear, or simply opening doors and windows, always do so. If the safety procedures seem inadequate, talk to your trade union Safety Representative, or the local Health and Safety Executive which can run a check on safety procedures in your workplace. This will be presented to the employer as a routine check, so they need never know that a member of the workforce has contacted the HSE.
Whatever you do, if you are in a risky job, don’t smoke. At a salmon processing plant in Scotland, 40% of the smokers developed allergies (resulting in asthma) to the fish allergens in the spray from the fish-gutting machine. Non-smokers - who formed the overwhelming majority of the workers - were not affected at all. In United States cotton mills, smokers are affected by levels of cotton dust in the air that are legally defined as ’safe’, while nonsmokers remain unaffected.
Passive smoking at work is also an important issue. A recent US study showed that non-smokers were more likely to develop asthma if they worked alongside a smoker. Your employer has a duty to provide you with clean air. This includes ensuring that other employees do not impose their cigarette smoke on you.
Respiratory equipment
Where respiratory equipment is needed, your employer must provide this, and it must be the right equipment for the job. It should be inspected, tested, cleaned and repaired after each use, and filters should be replaced regularly. All this is your employer’s responsibility, but check that it is being done, and always look the mask over before you put it on.
Two different types of respiratory equipment are currently in use:
• Those that give you a supply of air from outside the work area, either from a compressed-air cylinder, or via an air-hose (airline) supplied with fresh air. In Britain these are called breathing apparatus.
• Those that use the surrounding air but filter it to remove allergens and asthmagens. In Britain these are called respirators. (In some countries this term describes any kind of respiratory equipment.) Ordinary respirators may pose problems for some asthmatics because they cannot breathe in strongly enough to draw sufficient air through the filter. Powered respirators can be the answer: they have a battery-powered unit to help with pulling in the air.
There are government regulations concerning the type of equipment required for each type of allergen and asthmagen. Large companies generally follow these regulations, but small businesses, such as local sawmills, joineries and car-repainting workshops, may not even know about them.
Any respiratory equipment that has a face mask must form a tight seal with your face. Facial hair will prevent this, and so will stubble, so shave carefully. Faces vary enormously in shape, and if your face mask does not fit, ask for a different type of mask or a different type of respiratory equipment. Persist until you get one that’s right for you.
Carry out a ‘fit check’ each and every time you wear the mask. For example, with respirators, you can check the fit by covering the air intake completely with your hand and breathing in sharply: if the mask fits properly, it should collapse onto your face, and remain stuck to your face for several seconds. Look at the manufacturer’s instruction booklet as there may be a specific fit check recommended for the equipment you are using.
If there is any difficulty in breathing through the respiratory equipment, the replaceable filter cartridge or the equipment itself should be replaced. You should also take action immediately if you can smell the substance being handled – but never rely on this as a danger sign, because an extremely small amount, way beyond the detection capacity of the human nose, may be very damaging indeed to your health.
Keep your mask on throughout the work period. If you find this impossible, talk to your employer or
line manager about getting a different kind of respiratory equipment – a powered device, for example, that assists the inflow of air.
No form of respiratory equipment provides complete protection against allergens and asthmagens: there is always the chance of some small amount getting through. This is why respiratory equipment should not be used by those who have already developed occupational asthma but want to stay in their job.
Those who really cannot change jobs (e.g, farmers) are sometimes able to use a powered respirator helmet, which allows them to go on working despite the allergen. But this is not an ideal solution from a purely health point of view. Farmers can also improve matters, where moulds are the source of allergens, by keeping all harvested crops dry and thoroughly ventilated.
A lasting problem
As long as you catch the problem early, and are no longer anywhere near the allergen, your symptoms should disappear completely, but remember that you may still be highly sensitive to the allergen, even years afterwards. For a year or two at least, avoid contact with it again, even in tiny amounts. If someone else in your family works at the same place, they may bring home traces of the allergen on their clothes and hair: ask them to leave their workclothes outside the house and shower on arriving home.
With occupational allergies to airborne food particles, it is possible that the affected individual will later react to the same food when eaten. Experiment very cautiously, especially if the allergen is fish or shellfish.
The allergy may persist long after the job has ended. In one case, doctors found that a woman who had developed ‘baker’s asthma’, while working briefly in a bakery when young, was still allergic to the enzyme additive in bread 20 years later. She suffered an asthma attack whenever she ate bread.

Allergy: Selecting the Right Food

An avoidance diet is for people who already know what food or foods affect them, and simply need to

avoid those foods. A diagnostic diet is for those whose symptoms suggest that they might be suffering

from food sensitivity of some kind, and who cannot be diagnosed by indirect methods such as skin tests,

because true food allergy is not involved. A diagnostic diet is intended primarily to show whether or

not food is causing the symptoms.
The diagnostic diets themselves fall into two basic categories. Firstly, there are diets that, by a

process of elimination, identify a particular food (or foods) as a cause of symptoms. Called

elimination diets, these are used to diagnose idiopathic food intolerance (see p. 74) and certain other

kinds of sensitivity reactions to particular foods. An elimination diet is purely diagnostic - simply a

means to establish which foods are at fault. To this end, all commonly eaten foods are avoided at the

outset, and each food is then tested individually. Once an elimination diet is complete, the

information gathered is used to establish a suitable avoidance diet. For example, if milk, wheat and

oranges caused symptoms during the testing phase of the elimination diet, those foods are all avoided

in future.
Secondly, there are specific diagnostic diets, which are a great deal simpler to carry out than

elimination diets. A specific diagnostic diet aims to reduce the intake of a particular substance that

is found in certain foods. The substances concerned -histamine or nickel, for example - are known to

cause particular symptoms in susceptible people.
A specific diagnostic diet simply cuts out all the foods that contain large amounts of the substance
under suspicion. If this diet alleviates the symptoms, and does so consistently, it is plausible that

the substance concerned is indeed the culprit. However, the diet should be stopped and then started

again, preferably several times, to check the response. Once the sensitivity is confirmed in this way,

the avoidance diet which follows is basically the same as the diet used for diagnosis.
Note that there is no agreed terminology for these different kinds of diet, and the definitions given

above will not necessarily be followed in other publications. You may even come across ‘elimination

diet’ being used to mean ‘avoidance diet’, which is particularly confusing. If you are consulting other

sources of information, check the context carefully to see what meaning is intended.
There is one odd man out in this chapter - the diet to protect against asthma, described on pp. 206-7.

It is neither an avoidance diet nor a diagnostic diet, but a health-promoting diet of the kind commonly

advocated to combat other widespread conditions, such as cancer and heart disease. In fact, it has a

remarkable number of similarities to diets that reduce the risk of these other diseases.
The anti-asthma diet is immensely healthy, whereas many avoidance diets carry a risk of malnourishment.

An allergic individual following any kind of restrictive diet - especially a child - should be

medically assessed for the possible risks. That is why it is important to talk to your doctor before

starting any dietary treatment or investigation. A referral to a dietician or nutritionist may be

necessary, and your doctor can arrange this.
When malnutrition does occur as a result of self-treatment, there are often very complex factors at

work. One potential hazard with dietary treatment is that psychological problems can easily become
entwined with obsessions about food. Eating can be a potent form of self-expression, or a way of

exerting control over oneself and others. Many doctors have seen patients who are mistakenly convinced

that food sensitivity is at the root of their health problems, or those of their children. In some

cases, no amount of objective evidence to the contrary will deflect people from such beliefs.
A few people with mistaken beliefs of this kind impose very restrictive diets on themselves - or

sometimes on the whole family. The food rules that they establish may be a way of limiting contact with

the outside world, avoiding other problems and issues by making diet the central focus, or simply

making demands on other people’s time and attention.
The current fad for identifying ‘food allergy’ using very dubious diagnostic tests (see p. 93) will

probably send many more psychologically vulnerable people down this route.
Another unhelpful trend in the dietary field is the wholesale (and usually ineffective) use of

vitamins, minerals and other supplements for a great variety of diseases, including allergy and other

forms of sensitivity. It is important to realise that none of the sensitivity diseases described in

this book has nutritional deficiency as its primary cause, so supplements are not a major part of

treatment in most cases. For the majority of people with some kind of sensitivity disease, a supplement

will make only a small difference, if any. However, it is true that, with some sensitivity problems,

certain supplements may be helpful to certain individuals. The use of Vitamin C in asthma (see p. 207)

is one example of this, and there are some other instances mentioned in Chapter 2.
Generally speaking, it is better to get the vitamins, minerals and other nutrients you need (such as
antioxidants) from food, not from tablets. Studies of adult-onset asthma have shown that only natural

Vitamin E protects against the disease: supplements have no effect.
Many vitamins and minerals, along with various plant and animal extracts, are now referred to as

nutriceuticals - in other words, substances that are classed as nutritional supplements for legal

purposes, but are being marketed as if they were medicinal drugs (pharmaceuticals). Many doctors are

concerned about this, if only because of the duplicity involved. These substances can be sold freely to

the public only because they are, in theory, nutritional supplements, yet they are actively promoted to

the public as if they were drugs.
The marketing is usually indirect, to avoid falling foul of the law, but very effective nonetheless.

Advertisements for the product avoid making any medicinal claims, since these would be unlawful, and

just speak vaguely of ‘health-giving properties’. The specific medicinal claims are made in magazine

articles (which often appear right beside the advertisement), penned by journalists who have been

supplied with a great many ‘facts’ - actually unsubstantiated claims -by the manufacturer of the

supplement. These claims are reproduced uncritically, so the journalists are simply acting as

mouthpieces for the manufacturer. There is no law preventing this.
This is a ruse that circumvents important laws intended to protect consumers from misleading

advertising. Few of these products are likely to be damaging - although there are concerns about some,

especially beta-carotene supplements (see p. 207). What matters here are the large amounts of money

being made from products that frequently have few benefits for those who take them.

What exactly is in ready-made food? People with food sensitivity, especially those with severe food

allergy or coeliac disease, need a simple answer to this question, but frequently they don’t get one.

Research among food-allergy sufferers has found that, in the course of a year, half of them

inadvertently eat the food they are trying to avoid, owing to a lack of information about ingredients.

Restaurants and canteens are responsible for many of these accidents, and most of the fatalities (see

p. 111), but packaged food also plays a part.
Unfortunately, many food ingredients that are potentially allergenic, such as milk and eggs, appear in

packaged food without this being stated on the label in everyday language. The information is usually

there somewhere, however – you just need to know what words to look for.
Decoding food labels
The problems with food labels fall into two general categories:
•    some of the ingredients are described using technical terms. These are usually specific

constituents of the original foodstuff e.g. lactalbumin, one of the proteins found in milk.
•    some manufactured ingredients can be made from different starting materials. So an item such as

‘edible starch’ could be made from either wheat or maize (corn), while ‘hydrolysed protein’ could be

made from soya, maize or yeast, sometimes with wheat added.
One day, no doubt, manufacturers will realise what a burden this type of obscure labelling imposes on

their allergic customers and will start using plain language. In the meantime, food-allergy sufferers

just have to learn all the terms that may be used for their culprit food or foods.
Labels used in health-food shops and delicatessens are another matter altogether. Here the problem is

with exotic-sounding items, such as kamut, which is actually an allergenic food (wheat).
Maize (Corn)
Items always made from maize: cornflour, cornmeal, cornstarch, dextrose, polenta
Items sometimes made from maize: baking powder, cereal starch, edible starch, food starch, glucose

syrup, hydrolysed protein, hydrolysed vegetable protein, malt, malt flavouring, modified starch,

modified food starch, starch, textured vegetable protein, vegetable gum, vegetable protein, vegetable

starch
Note that the gum on envelopes and stamps is sometimes made from maize, and that many medicines contain

cornstarch.
Eggs
Items always made from eggs: ovalbumin
Items sometimes made from eggs: lecithin (In fact this is rare in foods – lecithin is usually derived

from soya. Only in pharmaceuticals is lecithin likely to be derived from egg.)
Terms used for egg on cosmetics and toiletries: Ovum
Fish
Be very cautious when travelling. The use of fish meal as an ingredient of spicy sauces is common in

Southeast Asia, and in some parts of Africa. The strength of the spices may make the flavour of the

fish undetectable.
Milk
Items always made from milk: casein, casemate, lactalbumin, whey
Terms used for milk on cosmetics and toiletries: Lac
If you see the term ‘dairy-free’ on standard packaged foods, you can safely assume that the contents

are free from goat’s and sheep’s milk, as well as cow’s milk. But be more wary with homemade or locally

produced foods labelled ‘dairy-free’ - some
people think that ‘dairy’ refers only to cow’s milk.
Parev or pareve is a term used for kosher (Jewish) food that contains neither milk nor meat. However,

there can be contamination with traces of milk.
Lactose is a sugar produced from milk, and while it is not allergenic itself, it may contain a trace of

allergenic milk proteins. The amounts involved are tiny, and will only affect the most sensitive

individuals.
The label ‘non-milk fat’ sometimes misleads people if they just glance quickly at labels. The fact that

a product contains non-milk fat does not, of course, mean that it is entirely milk-free -remember to

look for all the synonyms of milk (see above).
Nuts
Items always made from nuts: frangipane, marzipan, praline
Standard packaged food will almost always include the nuts by name, but if you are buying other food

(e.g. from a stall selling home-made food) watch out for the above names.
Be very cautious about unrefined nut oils (see p. 110). Almond essence may be produced chemically, in

which case it is safe, but some is made from real almonds and could be allergenic.
Terms used for nuts on cosmetics and toiletries: Prunus, Juglans, Bertholletia, Corylus
Peanuts
Items always made from peanuts: arachis oil, groundnut oil satay sauce
Unrefined peanut oil should be avoided. This is not much used, and unlikely to be encountered except in

Indian and Oriental cooking. Most groundnut oil sold in Britain and Europe, or used in packaged foods,

is refined and considered safe (see p. 110).
Alternative names: arachide, beer nuts, cacahuete, earth nuts, goobernuts, groundnuts, monkey nuts
You are only likely to encounter these names on imported food, or when travelling. Always be very

careful with Indian or Southeast Asian food, where the use of peanuts is very common and often not at

all obvious. Avoid chocolate from Poland, which often contains peanuts that are not declared on the

label.
Items sometimes made from peanuts: hydrolysed vegetable protein. (The usual source is soya or wheat,

but some is derived from peanuts.)
Terms used for peanut on cosmetics and toiletries: Arachis hypogea, Arachis oil
Sesame
Items always made from sesame or containing some sesame: gomashio, halva, hummus (houmus), tahini, the

drink Aqua Libra
Alternative names: ajonjoli, berme, gingelly, teel, til, simsim
Check carefully for sesame in any food from a health-food shop or a stall selling home-made food, and

in foods from the Middle East, or Chinese packaged food (e.g. stir-fry oils). Sesame oil is always

unrefined and therefore allergenic (see p. 110). Watch out for contamination by traces of sesame in

bakeries and delicatessens where goods are sold unwrapped.
Term used for sesame on cosmetics and toiletries: Sesamum indicum
Shellfish
Items sometimes containing shellfish: curry paste, fish sauce and other sauces/pastes used in Southeast

Asian cooking
Standard packaged food should mention shellfish specifically, but you may need to read the label

carefully. Be cautious about bottles of imported sauce, and home-made or takeaway food.
Soya
Items always or usually made from soya: miso, soy sauce, textured vegetable protein, tofu, vegetable

protein
Items sometimes made from soya: hydrolysed protein, hydrolysed vegetable protein, lecithin, vegetable

gum, vegetable starch Changes in ingredients
Unfortunately, the ingredients of a product can change without any obvious warning on the label, or any

change in the packaging. You should always check the label in detail, every time - even on foods that

you have eaten before without any trouble.
Wheat
Items always made from wheat: bran, flour, graham flour, hard flour, strong flour, wholemeal flour

(there are non-wheat brans and flours, of course, but the words ‘bran’ or ‘flour’, without any

qualification, usually mean wheat)
Regional names for particular types of wheat: bulgur or bulgar wheat, Chilton, couscous, dinkel, durum,

einkorn, farro, fu, kamut, semolina, spelt, triticum, triticale (a hybrid of wheat and rye)
Items sometimes made from wheat: baking powder, cereal binder, cereal filler, cereal protein, cereal

starch, edible starch, food starch, hydrolysed protein, hydrolysed vegetable protein, modified food

starch, modified starch, starch, textured vegetable protein, vegetable protein, vegetable starch.
Assume that bread, crispbread, pastry, pasta and noodles are made from wheat, unless definitely

labelled otherwise (and read the label in detail too, because a little wheat is often added to items

such as rye bread and rye crackers).
Note that buckwheat is not wheat at all - it is not even a cereal. Nor does it commonly affect

coeliacs, as is sometimes claimed, though a few coeliacs may develop an intolerance reaction to it,

through eating it very regularly.
For more information on avoiding gluten, see p. 177.
Yeast
Items usually made from yeast: leavening
Items sometimes made from yeast: hydrolysed protein, hydrolysed vegetable protein
Labelling loopholes
Manufacturers do not have to include on the label:
•    Any ingredients used in an earlier manufacturing process e.g. yeast used to make bread for

breadcrumbs, wheat flour added to spices or mustard powder during the grinding process, or bread used

to innoculate blue cheeses with mould -this can leave minute traces of gluten in the cheese.
•    Residues left by substances used during processing, such as wheat flour used to dust processing

lines or prevent dried fruits from sticking together. Manufacturers do not need to declare these

residues on the label because the substance serves no function in the final product and is present in

amounts that are considered insignificant. The vast majority of those with coeliac disease or food

allergy will tolerate such microscopic traces, but the most sensitive individuals may not. Some

coeliacs are even affected by food additives manufactured from cereals (see p. 177).
•    The individual constituents of a composite ingredient (such as salami on a pizza), if that

composite ingredient makes up less than 25% of the finished product. This is called the 25% rule. As

from November 2005, this is all set to change, thanks to the European Parliament. The contents of a

composite ingredient like salami will be listed in full. A few composite ingredients with officially

defined contents (such as jam, or chocolate) can be listed just as ‘jam’ or ‘chocolate’ if they make up

less than 2% of the product. Likewise herb mix or spice mix, if less than 2%. But there are certain

items that must always be listed if they are anywhere in the product, and however small the amount.

They are: milk, eggs, tree nuts, peanuts, sesame, mustard, celery/celeriac, fish, crustacean shellfish

(shrimps, prawns, crab etc), soya, wheat and all other cereals that contain gluten. Sulphur dioxide and

sulphites must be listed if more than 1 Oppm. This list will be reviewed from time to time.
`May contain’ labels
Labels reading ‘May contain nut traces’ are springing up like weeds on packaged food. Similar labels

relating to sesame, milk and eggs are also starting to appear.
Allergy sufferers, suddenly unable to eat foods that they formerly enjoyed, feel very frustrated about

this development. Many suspect that these labels are often just a defensive tactic - warning off

consumers with food sensitivity when the chance of the food containing the allergen is actually very

small. The danger is that some allergy sufferers may stop taking the labels seriously. Teenagers, in

particular, are increasingly dismissive of ‘May contain’ labels, and this is a huge worry for parents.
Could the need for ‘May contain’ labels be eliminated altogether with more careful factory procedures?

The problem here is that, with nuts, perfect cleaning of production machinery is extremely difficult.

Most machines have nooks and crannies in which a nut from one production process can become lodged,

only to free itself later during the making of a non-nut product. It is quite possible that someone

could encounter a whole nut, or substantial pieces of nut, in a non-nut product. That is why no one

with nut allergy, even if it is relatively mild, should disregard ‘May contain nut traces’ labels.
Some makers of confectionery and biscuits have now set up dedicated nut-free production lines, with

stringent precautions to avoid any possibility of contamination. This allows them to market products

that are guaranteed nut-free. If you cannot purchase these locally, you may be able to order them by

mail or over the Internet (see p. 255).
Note that packaged foods that have been produced on nut-free production lines in the past can be

switched to different production lines, that necessitate a ‘May contain nut traces’ label.
In some cases, a product is manufactured in two separate places, one of which is nut-free, while the

other is not. Consequently, the same product may sometimes be sold with a ‘May contain’ label and

sometimes without. Don’t disregard these labels, however illogical they might seem.
Packaging errors
As most people with food allergy are now aware, ready-made foods sometimes go out in the wrong

packaging. Alarming cases that have occurred in recent years include hazelnut yoghurts labelled Toffee

Yoghurt, and Vegetable Bake (containing nuts) sold in packets intended for Vegetable Lasagne (no nuts).
Manufacturers are increasingly aware of the hazards and when mistakes are discovered, allergy

information websites and organisations such as the Anaphylaxis Campaign are quickly informed, so that

they can alert allergy sufferers.
Belonging to such an organisation (see p. 255), and/or checking websites regularly, is definitely

recommended for anyone with food allergy. However, you should bear in mind that no information service

can protect you completely from this hazard. The odds against it are high, but one day you might just

be the unlucky person who first discovers a packaging error by suffering an allergic reaction. To

protect yourself as far as possible:
When is a nut not a nut?
Those with nut allergies often worry about eating nutmeg and coconut. In fact, allergic reactions to

these are rare. People with nut allergy are no more likely to react to nutmeg or coconut than anyone

else.
Tiger nuts or chufa nuts are not nuts at all, but the roots of a sedge plant – they are most unlikely

to cross-react with true nuts.
Peanuts, botanically speaking, are not true nuts at all. They are legumes (pulses). There can be

cross-reactions with soya and/or lupin (proceed very carefully with this novel food ingredient) but

reactions with other pulses are rare. Cross-reactions with tree nuts such as almonds and Brazils are

quite common however (see p. 15). Many people with peanut allergy can in fact eat tree nuts, but they

should be aware that a cross-reaction could develop at some stage.
Because cross-reactions between tree nuts are so common, doctors tend to speak simply of ‘nut allergy’.

However, it is possible to be allergic to one type of tree nut, without being allergic to others.
•    always check that the food in the packet looks like the photograph on the packet
•    double-check, when you serve the food, by noting the conspicuous ingredients of the meal

(carrots, for example), and ensuring that they are indeed on the list of ingredients – any discrepancy

should make you suspicious
•    note the smell and appearance of any ready-made food, before you taste it. Do this even for

very simple things such as flavoured yoghurts
•    only have a very tiny mouthful at first, and if you have any tingling of the lips or other

symptoms, however mild, stop eating immediately (this is helpful for true food allergy only, not for

coeliac disease)
•    be especially cautious about vegetarian food if you are allergic to nuts or soya.
Latex in food
Those with latex allergy may react to very small traces of it in food. This sometimes occurs with

packaged food or restaurant food that has been prepared by workers wearing latex gloves. On one

occasion a highly allergic individual reacted to a water glass that had been handled by someone wearing

latex gloves. The amounts of latex involved are minuscule, and only affect those with severe latex

allergy. However, there is a strong case for workers handling food to wear non-latex gloves, especially

with the rise in cases of latex allergy.
There are also reports of people with latex allergy reacting (usually very mildly) to cold-seal

adhesives in food
wrappers, such as those used for ice cream. The reaction only occurs if the wrapper actually touches

the lips or mouth.

FOOD SENSITIVITY IN ASTHMA, ECZEMA AND OTHER ALLERGIC DISEASES
In 1995, medical researchers in North Carolina, USA, asked over a hundred dermatologists how they treated atopic eczema. All used standard treatments such as moisturisers and steroid creams, but only 14% mentioned the possible role of food to the parents of children with eczema.
Between them, the dermatologists in this study treated about 17,000 children with atopic eczema per year. Using the most widely accepted estimates for food sensitivity in atopic eczema –38% of eczematous children are sensitive to food – one can calculate that there were over 5000 children in this study area who might perhaps have benefited from avoiding a problem food, but whose parents were never told about this treatment option.
North Carolina is by no means unique. The situation is much the same in other parts of the world, which adds up to millions of children and parents not even being told about a treatment that is frequently effective.
Other allergic diseases (see right) can also be triggered by food, although the percentage of patients affected is much lower than for atopic eczema. Here too, many doctors are unaware of (or sceptical about) the possible role of food.
These reactions are best described as ‘food sensitivity’. They cannot be called food allergy (see p. 62) if there are no symptoms in the mouth or gut and if skin-prick tests are negative – as is often the case. Negative skin tests suggest that the reaction is not IgEmediated (see box on p. 12).
However, in some children with atopic eczema. the skin-prick tests to culprit foods are positive. When these foods are eaten after a period of avoidance, such children sometimes suffer an
immediate reaction, with symptoms typical of true food allergy. For these individuals, their atopic eczema seems to be a symptom of IgE-mediated food allergy.
How can an atopic eczema reaction in response to food be IgE-mediated in one individual and not in another? Research is finally beginning to answer this question (see pp. 18-19).
The allergic conditions that may sometimes be induced, or simply aggravated, by a non-immediate reaction to food are:
• atopic eczema (atopic dermatitis)
• asthma
• perennial allergic rhinitis (constantly blocked or runny nose)
• chronic sinusitis
• secretory otitis media (’glue ear’).
In all of these conditions, many other causes exist. Except in the case of eczema, the other causes are far more likely than sensitivity to food. This fact will weigh heavily with your doctor, whose instinct, quite sensibly, is to look for likely causes first.
Taking asthma as an example, food sensitivity is relatively unusual as a primary cause, whereas allergy to airborne items. such as pollen or house-dust mite, is very common. Food probably affects only 8-10% of asthmatics overall, but is much more important for those with brittle asthma (the most severe and unstable form), affecting as many as 60% in a recent study.
The pollen connection
People who suffer from both birch-pollen allergy and atopic eczema may have worsening eczema when they eat certain fruits and vegetables, e.g. apples and carrots. These same foods cause Oral Allergy Syndrome (see box on p. 63) in some with birch-pollen hayfever, but they can aggravate eczema without causing Oral Allergy Syndrome.
Diagnosis
Consider other likely allergens first. Look at p. 28 for the airborne allergens that could play a part in perennial allergic rhinitis, chronic sinusitis, secretory otitis media (’glue ear’), and asthma. Only in the case of children with atopic eczema is food a prime suspect (between 38% and 69% of children with atopic eczema are affected by food), but even here there are a lot of other factors to consider (see pp. 43-4).
If you do decide to investigate the role of food, don’t abandon basic treatments in the meantime. By neglecting these. you could make the whole problem a great deal worse.
There are various clues that food is at fault:
• If you have other symptoms that suggest food intolerance (see p. 76). These problems often seem to go together with food-induced asthma or rhinitis.
• If you have noticed that a particular food makes your symptoms worse. Where there is intolerance to one food, there could well be intolerance to another, which you have not noticed.
• If you have exercise-induced asthma (see p. 41) and sometimes respond severely to exercise but sometimes have little or no reaction. Sensitivity to a food or foods may be instrumental in changing the response to exercise.
• If you have brittle asthma – but you must get your doctor’s consent for an elimination diet. Foods must be tested under medical supervision as severe life- threatening asthmatic reactions can occur on testing.
• If there are also digestive problems such as diarrhoea, vomiting or belching. This is a strong clue in the case of children with atopic eczema. Symptoms such as diarrhoea frequently precede atopic eczema, and it seems likely that a reaction to food in the gut increases the leakiness of the gut wall, allowing more food molecules through to the blood.
• If there is pronounced eczema around the mouth in children (but this can also be due to constant licking),
• For adults with atopic eczema, if there is a persistent rash on the hands, or the lips. Where there is a blistering rash on the hands that erupts at regular intervals, food is often the problem – or it may be metal contaminants of food such as nickel (see pp. 55-6). In general, food sensitivity is rarer among adults with atopic eczema than it is among children.
Skin-prick tests (see p. 91) for commonly eaten foods are worth
trying in all the diseases – if they give a positive result, they should
be noted, but if they give a negative one, they should be disre-
garded. The many alternative tests being marketed (see p. 93) are
highly inaccurate and unlikely to help.
Research from Tampere University Hospital in Finland suggests that babies are much more likely to give false-negative skin-prick tests for food than older children and adults with atopic eczema. The Finnish researchers found that 52% of babies with atopic eczema give a negative skin-prick test despite having a genuine reaction when tested by food challenge. In an attempt to tackle this problem, they have devised a patch test, similar to those used for contact dermatitis. The patch test, in which food is applied to intact skin and left there for two days, gives false negatives in only 39% of babies.
The best way to detect food-sensitive eczema, according to Dr Erika Isolauri. who heads the Finnish research team, is to use both tests, and take note of a positive reaction to either. This detects 80-90% of eczema-causing food reactions in infants.
Few other doctors are currently using patch tests for atopic eczema; because so much controversy surrounds this topic, and no standardised method has yet been devised. You may be lucky and find a specialist who does these tests.
To confirm the role of particular foods in atopic eczema, a food challenge test is essential, having first avoided the food carefully for two weeks. Great care is needed in testing (see p. 198).
If you cannot get suitable tests done. a simple elimination diet will be needed (see p. 198).
Treatment
There is a choice here, between avoiding the offending food, or eating normally and controlling the symptoms with drugs.
The difficulty comes when parents have to make this decision on behalf of their children. Unfortunately, there is insufficient evidence as regards the consequences of this decision. Treating food sensitivity can reduce the eczema symptoms substantially in the short term, but it does not necessarily improve the long-term prospects for the child. Orthodox doctors tend to think that eating a normal diet is much better for a child nutritionally and socially, and they have a point.
Doctors with a special interest in food sensitivity generally believe that treating the problem at source, rather than just suppressing the symptoms with drugs, must take the pressure off the child’s immune system, and give the child a better chance of growing out of sensitivity reactions in the long run.
The decision is yours – but it is vital that the diet is not more of an encumbrance than the disease itself, and that the child’s interests come first (see pp. 170-71). Whatever you do, don’t allow a child to become malnourished (see p. 198).