Patients often need advice on how to maintain adequate nutrition and caloric intake while meeting the goals of food avoidance. need advice on how to maintain adequate nutrition and caloric intake while meeting the goals of food avoidance. The FDA’s Food Allergen Labeling and Consumer Protection Act of 2004 requires food labels to list any of the eight major food allergens contained in the product, regardless of the amount.17 The label of any food product that contains nuts or seafood must list the specific type. Food-allergic individuals should avoid all products with any precautionary labeling (e.g., “This product may contain trace amounts of peanuts”). The astute clinician will advise food-allergic patients to avoid any food product whenever uncertain of its contents. Hidden allergens contribute to the complexities of managing food allergies (Table 4).18 For example, patients with egg allergies must recognize that mayonnaise contains eggs and should be avoided. Patients should be provided with a list of possible covert sources of their food allergens. Additionally, food allergens often have several different names, and patients must be familiar with them. For example, milk can also be referred to as casein, hydrolysate whey, ghee, curds, and/or lactalbumin phosphate on a food label, and wheat can come in the forms of couscous, durum, farina, kamut, spelt, and/or modified starch. Changing the allergenicity (the capacity to elicit an IgE response) of a food may affect how provoking the food is to the patient. Heat from the manufacturing or baking process destroys the protein structure of food and decreases its allergenicity. Some milk-allergic patients may be able to tolerate milk in baked products but not when drinking it cold. Raw fruits and vegetables may cause reactions in some allergic patients, but such an indvidual may be able to tolerate those same fruits or vegetables after they have been cooked. Cooking oils are commonly derived from soy, corn, peanut, and sesame and may provoke food allergy symptoms. Oils range in their allergenicity depending on how much of the food protein is removed during the manufacturing process. Occasionally, small amounts of protein from the grain, nut, or seed remain in the oil. Pure oils are nonallergenic because these products do not contain a protein. Consuming highly refined oils developed from major allergenic food sources does not appear to be associated with allergic reactions for most patients. It is recommended that persons with peanut allergy avoid peanut oil since it is often quite difficult to ascertain the degree of oil refinement in the product. Sesame oil is often largely unrefined and should be avoided. Canola
oil (made from rapeseeds) appears to be the safest oil for patients to consume because it does not contain a protein. If a patient has only been skin-prick-tested or ssIgE-tested for a few select foods, questions may arise as to whether to avoid similar foods not subject to testing. Patients should be aware of foods that commonly cross-react with their food allergen and approach these foods with caution until the tolerability for the food is known (Table 5). For example, if a patient is allergic to peanuts (a member of the legume family), there is an increased risk of cross-reactivity with other legumes (e.g, peas, lentils, beans). Similarly, a patient who is allergic to latex faces an increased risk of cross-reactivity with banana, kiwi, and avocado. All patients should take appropriate care when consuming products that are known to cross-react with their allergens. Such food additives as dyes, preservatives, and artificial sweeteners are common causes of concern as potential triggers of food allergies and should be avoided by individuals who have TABLE 4. Hidden food allergens Allergen
Suspect foods
Egg
Bagels, pretzels, baked goods, bouillon, cereals, cakes, chocolate, custard, butter, pancakes, waffles, ice cream, mayonnaise, marshmallows, salad dressings, sherbets
Fish
Caesar salads, hot dogs, pizza toppings, imitation crab, Worcestershire and marinara sauces
Milk
Yogurt, butter, margarine, cheese, creams, custards, meatballs, pizza, frozen desserts, coffee, whey, caramel flavoring, ghee
Peanut
Artificial nuts, imitation nuts, beer nuts, praline, cakes, pastries, biscuits, ice cream, cereal bars, meat products, egg rolls, granola, cereals, candy
Shellfish
Shrimp, crab, lobster, oysters, octopus, scallops, escargot, fish stock
Soy
Soy flour, tofu, soy nuts, imitation seafood, dairy substitutes, textured vegetable protein, vegetable starch, vegetable broth, Asian cuisine
Tree Nuts
Pesto sauce, popcorn, doughnuts, desserts, cookies, candy, cereals, cheese spreads, chocolates, ice cream, granola, marzipan
Wheat
Breads, baked goods, pastries, pasta, cereals, crackers, cakes, cookies, snacks, processed meat, modified food starch, salad dressings, flour
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