Food Allergy – Indian Food Allergy – Indian ScenarioScenario

Dr. Ashok GuptaDr. Ashok GuptaAsso. Prof. of Pediatrics, SMS Medical College, JaipurAsso. Prof. of Pediatrics, SMS Medical College, Jaipur

Deputy Executive Director, International Society of Tropical PediatricsDeputy Executive Director, International Society of Tropical PediatricsExecutive, International Pediatric Academic Leaders AssociationExecutive, International Pediatric Academic Leaders Association

Medical Advisor, Food Allergy and Anaphylaxis Network, USAMedical Advisor, Food Allergy and Anaphylaxis Network, USAMember, EAACI Committee on Patient Group for Food AllergyMember, EAACI Committee on Patient Group for Food Allergy

Epidemiology of Diseases in IndiaEpidemiology of Diseases in India

S. No. Disease Total Cases Deaths Year

1 Acute Respiratory Infection 1,18,54,345 3736 2007

2 Acute Diarrhea Disease 94,78,813 2328 2007

3 Measles 26986 1995

4 Malaria 1363279 1066 2007

5 Japanese Encephalitis 4017 989 2007

6 Dengue 5395 69 2007

Continued…Continued…

• No registry of Food Allergy Patients

• No Medical college has a degree course in Allergy

• Demographic projections predict 22% of the total population suffer from some allergy (250 million)

CaseCase

• Avinash – 8 year, Male, h/o Peanut Allergy

visiting from USA– Consumes packaged food with inadequate

information, develops anaphylaxis

– July 6, 2010, Union Minister of Health, GOI accepted Food Allergy as a serious health problem

CaseCase

Anil – 1 yr. Male

• Milk Ingestion induces – flushing, swelling, breathing difficulty

• Milk anaphylaxis

CaseCase

Shrichand – 5 yrs. Male

• Repeated papular urticaria

• Partial response to antihistamines

• Allergy test – wheat allergy

• Improved on wheat withdrawal

CaseCase

Vicky – 5 yrs. male

• Chronic Diarrhea

• Failure to thrive

• Rickets

• Multiple nutritional deficiencies

• Celiac Disease

Adverse Food Reactions may be mistaken Adverse Food Reactions may be mistaken for allergy for allergy

Toxic / PharmacologicToxic / Pharmacologic Non-Toxic / IntoleranceNon-Toxic / Intolerance

• Bacterial food poisoning• Heavy metal poisoning• Scombroid fish poisoning• Caffeine• Alcohol• Histamine

Non-immunologic

• Lactase deficiency• Galactosemia• Pancreatic insufficiency• Gallbladder / liver disease• Hiatal hernia• Gustatory rhinitis• Anorexia nervosa• Idiosyncratic

Adapted from Sicherer S, Sampson H. J Allergy Clin Immunol 2006;117:S470-475.

• Eosinophilic esophagitis

• Eosinophilic gastritis

• Eosinophilic gastroenteritis

• Atopic dermatitis

Adverse Food Reactions Adverse Food Reactions

IgE-MediatedIgE-Mediated(most common)(most common)

Non-IgE MediatedNon-IgE MediatedCell-MediatedCell-Mediated

Immunologic

• Systemic (Anaphylaxis)

• Oral Allergy Syndrome

• Immediate gastrointestinal allergy

• Asthma/rhinitis

• Urticaria

• Morbilliform rashes and flushing

• Contact urticaria

• Celiac disease

• Protein-Induced Enterocolitis

• Protein-Induced Enteropathy

• Eosinophilic proctitis

• Dermatitis herpetiformis

• Contact dermatitis

10

Natural history of food allergyNatural history of food allergy

• Generally - reproducible reaction: same person, same food, same, similar or related symptoms

• May progress from dermatitis or hives to vomiting & wheeze to Asthma and Anaphylaxis

• ~ 85% of individuals with allergies to cows milk, egg, wheat, soy become tolerant by 3 yrs of age

• Allergy to peanut, nuts, seafood is typically permanent

Allergens Common in IndiaAllergens Common in India

• Any food can be allergenic• Patterns of common allergens differ across

regions and cultures• Dairy, eggs, peanuts, tree nuts such as walnuts,

almonds and cashews, fish, shellfish, soya, wheat, seasame top the list

• Incidence of allergies to milk, eggs and wheat less frequent then in the West

• Dals (Pulses) such as chickpeas more common allergy to rice has been reported

Allergy distributionAllergy distribution

• Evenly distributed

• More in urban and semi urban areas as compared to rural areas

• Changing food pattern moving away from Traditional Dal, Rice, Vegetables to Fast Food, Ice cream, Chocolate additionally increased Houses have Carpets & Pet

Food allergy

IgE-mediated food allergy

Non-allergicfood hypersensitivity

Non IgE-mediated food allergy

FoodhypersensitivityFood hypersensitivity

Food hypersensitivityFood allergy  

IgE-mediated allergy 

Non-IgE- mediatede.g. celiac disease

  

Non-allergic-foodhypersensitivity

Enzymatic- lactose intolerancePharmacological

- biogenic amines e.g. histamine, tyramine

Allergens from a single siteAllergens from a single site

No. of Tests- 66778 (2008 & 2009)Name of Allergen Percentage allocation

Mite 36.1

Cockroach 32.5

Asp.Fum. 28.8

H.dust 21.8

Bermuda grass 21

Shrimp 18

Johansson grass 15.9

Wheat 12.4

IgE mediated Food Allergens in patients with Asthma and allergic rhinitis.

No. of patients- 1860 patient.

Curd 48 %

Rice 43%

Citrus 35 %

Banana 27 %

Milk 12 %

blackgram 9.7 %

Egg 2.7 %

Chicken 1.5 %

Fish 1.2%

Studies on large scale surveysStudies on large scale surveys

• Moshe Ben-Shoshan etal, Montreal, Canada – Population based study on Peanut, Tree nut, Fish, Shellfish, and Sesame allergy prevelance in canada

• EuroPrevall

• Gerez etal – Singapore Medical Journal

Definition of Food AllergyDefinition of Food Allergy

• Perceived food allergy – Self reported

• Probable Food Allergy – Self reporting / Physician confirmed

• Confirmed Food Allergy – Convincing clinical history of IgE reaction / positive SPT

Methodology Methodology

• Telephone surveys

• Trained Interviewer

• Respondents 18 years older with no language mental hearing barriers

• Questionnaire

• Statistical Analysis

No. of New Celiac casesNo. of New Celiac cases

0

20

40

60

80

100

120

2002 2004 2006 2008 2010

Celiac Patient

Distribution of Celiac Diseases Distribution of Celiac Diseases CasesCases

Rural

Urban

24%

76%

ComplianceCompliance

• Rising incidence of symptomatic celiac patients• Need for appropriate education of parents,

children & medical personal• Need for strategies of prevention

- Delayed introduction of gluten- Breast Feeding

• High index of suspicious in children with Typical presentations & in asymptomatic IDA, Hypothyroid, 1st degree relicts.

• IDD & Hypothyroid not responding to treatment need to be screamed.

• Regulatory mechanism for labeling & assessing of gluten free products.

KAP Anaphylaxis

Medical College Faculty & Residents - 32%

General Practioner - 9.2%

Food Allergy diagnosis

Medical College Faculty & Residents - 44 %

General Practioners - 11.2%

ConclusionsConclusions

• Food allergy on the rise• Need for establishing a national registry• Urgent need to educate medical personnel • Social & Psychological cost to the patient and

the family• Food labeling• Scientific support on preventing food allergy &

making food safe• Quality control of marketed foods