With so many Internet resources available on salicylate sensitivity and histamine intolerance – where fruits are a big culprit – it is easy to get the impression that adverse reactions to fruit are signs of food intolerance and not food allergy. But even though fruit are not included in the Big 8 list of allergenic foods (except for nuts, which technically are fruit), it is still possible to develop fruit allergies and even suffer anaphylaxis from fruit. In fact, since most allergy symptoms overlap with food intolerance symptoms and both types of reactions can be delayed, you should not try to distinguish between the two conditions on your own.
Fruits, vegetables & allergy
The following fruits and vegetables are most often implicated in allergy. This list is not exhaustive – other fruits are possible.
Primary fruit allergy is just like any other food allergy: specific proteins unique to fruits (lipid transfer proteins) bind to IgE antibodies and trigger the release of histamine and other chemicals. Symptoms are the same as classic allergy symptoms and develop along similar time frames.
Oral allergy syndrome (OAS), also known as pollen-food syndrome, is most common food allergy in adults. In order to suffer from OAS, you must have an existing allergy to pollen or latex. OAS occurs because certain proteins in fruit are similar enough to plant proteins that they can also bind to pollen-specific IgE antibodies and trigger symptoms. Symptoms arise rapidly – between 15 minutes to 1 hour after eating fruit – and typically include itching or hives in the mouth and throat. However, gastrointestinal and systemic symptoms are also possible, and foods related to birch pollen can also cause or aggravate chronic eczema in children and adults.
The worldwide prevalences for primary fruit allergy and for OAS are both around 5%. The prevalence rates and predominant types of fruits and vegetables involved vary from country to country. OAS is often regarded as a mild condition, but about 2% of people with OAS could experience anaphylactic shock. Taking ACE inhibitors for hypertension or congestive heart failure amplifies OAS symptoms, and this could lead to facial swelling that stops you from being able to breathe.
If you do have a fruit allergy or OAS, a doctor can answer your questions about managing your condition: Should you completely avoid your trigger foods? How much could you safely eat? Should it be cooked or peeled? Which varieties of troublesome fruits should you shop for?
If your doctor tells you that you do not suffer from a fruit allergy or OAS, then you can probably pursue a diet investigation for food intolerance with a registered dietitian – get your doctor’s OK. Remember, if you are a person who experiences laryngeal edema (swelling of the throat or upper airways), food challenges for food intolerance should be done only in a clinical (inpatient or outpatient) setting.
American College of Allergy, Asthma and Immunology (ACAAI). Oral allergy syndrome, high blood pressure medications can create lethal cocktail. [Internet] ScienceDaily; 2013 November 13. Available from: http://www.sciencedaily.com/releases/2013/11/131108090135.htm [Accessed 2014 January 18] (Archived by WebCite® at http://www.webcitation.org/6Oja4p5cB).
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Skypala I. Fruits and Vegetables. In: Skypala I, Venter C, editors. Food Hypersensitivity: Diagnosing and Managing Food Allergies and Intolerance. John Wiley & Sons; 2009. p. 147–65.
Imagine that you are in a Chinese restaurant with your family. You’ll probably get a migraine later tonight (maybe from the amines in the soy sauce), but you’ve been craving Chinese food all week and you haven’t made the connection yet. Your daughter is drinking cup after cup of jasmine tea with her five spice stir fry, and this, combined with the other things she ate during the day, will give her hives again this evening. Your son asks you to read the fortune in his fortune cookie – “Knowledge is power,” it says, but it doesn’t warn you about the tartrazine in the cookie. He’ll be cranky tonight and distracted tomorrow morning. This is what you might experience if you suffer from food intolerance.
Lesson 1: What is food intolerance?
Is food intolerance real?
Yes. The existence of pharmacological food intolerance has been established by double blind placebo-controlled food challenges. The bulk of the research on food intolerance has been conducted in Australia, the UK, and Germany, and there is an increased awareness of food intolerance in these countries.
That said, two points should be kept in mind. First, even though food intolerance is real, it is relatively rare. These reactions are aptly categorized as ‘hypersensitivity‘ reactions, meaning that most people – perhaps 99% depending on the substance – will not experience any problems from food chemicals at normal amounts. Second, not all evidence carries equal weight when it comes to the different trigger chemicals, and many questions still need to be answered.
Food intolerance, as defined by the Allergy Unit at the Royal Prince Albert Hospital in Australia, is a sensitivity to chemicals found in a wide variety of foods. It is also known as pharmacological food intolerance, a type of non-allergic food hypersensitivity. Food intolerance does not involve the immune system.
The term ‘pharmacological’ is related of the nature of the substances that elicit food intolerance reactions. In addition to nutrients, foods contain chemicals that are foreign to our bodies (like benzoate in fruit or artificial colors in yogurt) or excess amounts of chemicals that our bodies normally produce (like tyramine or histamine in certain cheeses). This is obvious in the case of processed foods, but it is true for fresh or organic foods as well. The foreign or excess chemicals are processed in the body along the same lines as drugs, and in food intolerant people, they also produce drug-like effects. But why would such chemicals be present naturally in food? Because they are important to plants or because they are part of the normal ripening and aging processes.
Food intolerance is different in each person. Some people will be sensitive to certain trigger chemicals for their entire life, and these people will need to avoid foods that contain these chemicals in order to remain symptom-free. Others will only need to avoid their culprit foods for a time until they can resume eating them – perhaps in limited quantities – without seeing symptoms. Still others might only see problems when they eat large amounts of their offending foods or eat certain combinations of foods. But for everyone, the key to living life to the fullest is an accurate determination of which food chemicals are causing the problem. A registered dietitian or doctor can help you find your triggers through an elimination diet and food challenges.
Lesson 2: Food triggers linked to food intolerance
Table 1 contains the most commonly discussed food triggers linked to food intolerance. More than one trigger can be present in a given food, making it difficult to determine which foods contributed to your symptoms. Please be aware, though, that not all of the chemicals listed below are implicated in food intolerance by the same degree of evidence — for all the details, I recommend this recent open-access review:
Alcohol can modulate, for better or for worse, the effects of some food chemicals by increasing their absorption or altering their breakdown.
Lesson 3: Food intolerance symptoms
Food intolerance symptoms can arise hours or even days after eating a trigger food, and their severity depends on how much you ate, what you ate during the previous few days, and whether you have other health conditions. On top of this, symptoms can be aggravated by illness, environmental chemicals (like fragrances), medications, hormonal changes, or stress. The most common symptoms of food intolerance are given below.
System
Symptom
Skin
Hives (urticaria), swelling (angioedema), itching, aggravation of eczema
Migraine, vertigo, fatigue, muscle pain (myalgia), growing pains, behavioral changes in children
Generalized
Non-immune anaphylaxis
Lesson 4: Food intolerance as a food hypersensitivity
Adverse reactions like food intolerance and food allergy are classified as hypersensitivity reactions, where the concept of hypersensitivity has real meaning. Food hypersensitivities are reproducible reactions brought about by quantities of foods that most people can tolerate. In other words, to classify an adverse reaction as a food hypersensitivity, you must first think about the effect that a normal amount of that food would have on the average person.
Food hypersensitivities are divided into two main groups: those that are caused by the immune system (immune-mediated hypersensitivities) and those that aren’t (non-immune mediated hypersensitivities). If we consider food allergy – the poster child for immune-mediated food hypersensitivities – it is easy to see why hypersensitivity is an appropriate description. Allergies occur when the immune system overreacts to harmless proteins in foods, like milk, eggs, wheat, and soy, that lie at the heart of the Western diet. Only about 5% of the overall population is suffering from some type of food allergy, and the amount of food needed to trigger an allergic reaction can be much less than a typical portion.
There are more immune-mediated food hypersensitivities than just food allergies. These reactions involve other aspects of the immune system and may take a longer time to develop than a classic allergic reaction. Here I’m talking about problems like cow’s milk protein intolerance, soy protein intolerance and food protein induced entercolitis in children, celiac disease, and eosinophilic esophagitis — in some cases, asthma and eczema are also related to food. Notice that these conditions are occasionally lumped under food intolerance (and ‘intolerance’ even appears in a few of the labels), but strictly speaking, these are immune reactions.
The term food intolerance is used as the common name for non-immune mediated food hypersensitivities. The best-known type of food intolerance is lactose intolerance, the gastrointestinal discomfort that results from undigested lactose (milk sugar) in the colon. Roughly 75% of the world’s adults — 25% in the US and even fewer in northern Europe — do not produce enough lactase to digest all of the lactose they consume, but not all of these people will experience symptoms and, thus, lactose intolerance. In lactose intolerance, symptoms depend on a person’s gut bacteria and eating habits.
Pharmacological food intolerance, the focus of this primer, is also a non-immune mediated food hypersensitivity. For example, consider a person who has worked with their doctor to determine that their headaches and diarrhea are symptoms of histamine intolerance. In histamine intolerance, a person’s ability to break down histamine is impaired, so foods that are rich in histamine or that cause histamine to be released in the body can lead to symptoms. Histamine intolerance is a food hypersensitivity, because most people can tolerate normal quantities of histamine-rich or histamine-releasing foods.
That said, how do we gauge what “most people” can tolerate? As with food allergy and other immune-mediated food hypersensitivities, the non-immune hypersensitivities generally affect less than 10 or even less than 5% of the population. For example, less than 1% of adults are sensitive to food additives, at least 1% have histamine sensitivity, and around 6% suffer from food-induced migraines. This means that for any food hypersensitivity, perhaps 99% of people will experience no adverse reactions to those foods or food chemicals.
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