3.  Case 1--38 year old man states that he is
deathly allergic to onions and must have an
onion free diet.
 Case 2--19 year old man states that he is
allergic to peanuts and has avoided them
since childhood.
 Case 3—29 year old female states she is
allergic to milk. She requests a substitute for
milk in her diet trays.

4.  Understand IgE
mediated allergic
reactions
 Know the incidence
and risk of Food
Allergy adverse events.
 Know how to confirm
food allergy by history
and testing.

5.  Toxic Food Reaction
 Food Intolerance
 Food Allergy
 Non-IgE mediated
▪ (Celiac Disease)
 IgE mediated

6.  Salmonella
 Hangover

8.  Most occur in children
< 3years old
 Local reactions
 Poison Ivy reaction
 Food allergy causing oral
reactions
 Celiac disease
 Not acute
 Takes time to diagnose

9. IgE sensitized.
Attaches to Mast Cell
Awaits next encounter
with the allergen.

10. Allergen attaches to IgE
Mast cell destabilizes
Releases
Histamine
Prostaglandins
Leukotrienes

11.  Urticaria
 Angioedema
 Respiratory
 Anaphylaxis
 Urticaria and
angioedema are by for
the most common
allergic reactions

15.  Cardiovascular
symptoms
 Hypotension
 Vascular collapse
 In conjunction with
skin and respiratory
symptoms

16.  Gastrointestinal Hypersensitivity
 Usually kids
 Vomiting, diarrhea, cramps
 Minutes to 2 hours after eating.
 In conjunction with hives and angioedema.
 Exercise induced food allergy

17.  Occurs in seconds to
minutes.
 Takes only a small
amount of allergen to
cause reaction.

18.  Mostly a disease of
childhood
 Allergies tend to abate
with age

19. CHILDREN ADULTS
 Cow’s Milk  Peanuts
 Eggs  Tree nuts
 Shellfish
 Wheat
 Peanuts, Tree nuts  Fish
 Fruits and
vegetables

20.  Food Allergy Deaths:
100/year
 Penicillin allergic
deaths: 400/year
 Latex allergy
anaphylaxis: 220/year
 NSAID related deaths:
25,000/year

21.  Most deaths are
teenagers/ young adults
 >85% are due to peanuts
and tree nuts
 Virtually all had asthma.
 Virtually all had had a
previous severe reaction
to the same food.
 Virtually all did not
receive epinephrine in a
timely fashion.

22. Right Age?
Right Food?
Emergency treatment?
Allergist? Testing?
EpiPen? Medic Alert?
Restaurants? Shopping labels?

24.  Skin Prick Test
 Easy to do.
 Inexpensive.
 Results in 15 minutes.
 Requires training and
supplies.
 Great for large jails.

25. ImmunoCap Radioallergosorbent test
Measures IgE to specific antigens.
 Accurate and predictable.
 $45.00. Is this cost effective?

26.  Positive defined as
greater than 2.0kU/L
 Sensitive but not
specific.

30.  Sensitive, not specific.
 If negative, believe it.
 If positive, the patient still may not be
allergic.
 Expensive--$45.00.
 May be less expensive than the costs of a
special diet.

31.  Of those referred to an allergist, <50%
are actually allergic.
 What about those coming into a jail or
prison?

32.  Ada County Jail is a
1200 bed facility
located in Boise, Idaho.
 Over a two year
period, virtually all
inmates who stated
they had a food allergy
were tested.

33. Allergen Number of Tests Number Positive Percent Positive
Peanuts 39 5 13%
Finfish (Tuna, Cod) 34 0 0
Cow’s Milk 12 0 0
Vegetables 10 0 0
Oatmeal, Wheat, 10 0 0
Rice, Gluten
Shellfish 5 2 40%
Tree nuts 5 0 0
Fruits 4 0 0
Poultry 4 0 0
Beef 3 0 0
Egg 2 0 0

34.  Case 1--38 year old man states that he is
deathly allergic to onions and must have an
onion free diet.
 Case 2--19 year old man states that he is
allergic to peanuts and has avoided them
since childhood.
 Case 3—29 year old female states she is
allergic to milk. She requests a substitute for
milk in her diet trays.

35.  Risk of anaphylaxis.
 Food avoidance.
 Emergency response.

36. HIGHER RISK LOWER RISK
 Teens to Early 20s  Older
 Previous severe reaction  Not the Big 3 foods
 Peanuts, Treenuts, shellfish  No documentation of
previous severe reaction

37.  Special Diet
 Kitchen Worker?
 Cell or dorm where others eat the allergic
food?

38.  Epipens?
 Emergency Response?

39.  Don’t serve “The Big 3
Foods”
 Substitute Foods.
 Testing--skin prick test
and CapRAST.

40.  Work up protocol
 Peanuts, fish
 CapRAST, Skin prick test
 Tomatoes, onions, etc.
 History test
 CapRAST, Skin Prick

41.  CATEGORY: MEDICAL AND NUTRITION

 TOPIC: FOOD ALLERGIES

 PURPOSE: TO GUIDE APPROPRIATE IDENTIFICATION AND TREATMENT OF PATIENTS WITH FOOD
ALLERGIES


 References. This protocol is based upon the following sources.
 Adkinson: Middleton’s Allergy: Principles and Practice, 7th ed. Chapter 65—Adverse Reactions to Foods
 Food Allergy: Diagnosis and Management. Primary Care: Clinics in Office Practice. Vol. 35, issue 1 (March 2008)
 Rakel: Integrative Medicine, 2nd ed. Chapter 86—Adverse Food Reactions and the Elimination Diet
 Introduction to food allergies in corrections
 In a correctional setting, the differentiation of true food allergies from food intolerance (especially simple food aversion) is essential. On the one hand, jails
do not want someone with a true food allergy to be served that food and suffer an allergic reaction. On the other hand, most inmates who claim to have a
food allergy only have a food aversion and jails cannot feasibly grant a special diet to everyone like this.
 Inmates who have no true allergy may use the claim of an allergy to avoid foods they do not like, in order to gain status among other inmates and to
manipulate staff.
 The goal of this endeavor is to accurately identify those individuals with a true food allergy and exclude those who do not have a true food allergy.
 Definitions.
 Food Allergy refers to an immune-mediated allergic reaction to the glycoproteins in certain foods.
▪ Food allergies are most common in the very young.
▪ Many patients with true food allergies loose the allergy over time.
▪ Several studies indicate that most patients who report a true food allergy are found by diagnostic testing to not have that allergy in fact.
▪ Most cases of true food allergies are to certain foods: nuts, shellfish, eggs.
▪ An estimated 200 people die each year from acute allergic reactions.
▪ Most of these deaths are due to peanut or tree nut allergies.
 Food Intolerance refers to any non-allergic reaction to food. Food intolerance includes:
▪ Food poisoning due to a toxin.
▪ Side effects of substances found in some foods (example, headache caused by tyramine in wine or racing heart caused by caffeine).
▪ Individuals lacking certain digestive enzymes, such as those with lactose intolerance and those needing pancreatic enzyme replacement.
▪ Food aversion in which patients have a psychological revulsion for certain foods but experience no problems when they ingest that food unknowingly.
 Adverse Food Reaction includes both food allergy and food intolerance. This term is used when it is not yet known if a patient has a true allergy or not.

42.  38 year old man states that he is deathly
allergic to onions and must have an onion
free diet.
Right Age? Right Food?
History--ER? Allergist? Testing?
EpiPen? Medic Alert?
Restaurants? Shopping labels?

43.  19 year old man states that he is allergic to
peanuts and has avoided them since
childhood.
Right Age? Right Food?
History--ER? Allergist? Testing?
EpiPen? Medic Alert?
Restaurants? Shopping labels?

44.  An IgE milk allergy in an adult is rare.
 The most common causes of milk “allergy”
are:
 Intolerance (eats ice cream and cheese)
 Lactase deficiency (truly avoids dairy)
 Treatment is Lactaid—on commissary.

45.  Slides
 Outline
 Ada County Jail Food
Allergy Protocol
 Questions