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  Understanding the interconnections among inflammation, environmental allergies, food allergies, food sensitivities, processed foods, sugar, and autoimmune diseases can make an extraordinarily large difference in the life of a patient who is suffering from anything that has to do with inflammation. And as you know by now, that’s the case for most chronic illnesses.

  As I continued down this path of testing kids for food allergies and advising their parents on nutrition, it quickly became apparent how gray the world of food allergy testing is compared to swabbing a child’s throat and looking for the Strep bacteria. Bodily inflammation caused by foods can be triggered through several different pathways, not just the ones tested in the IgE blood or skin prick tests. For example, I might test five kids with constipation symptoms similar to Javier, but in three of them, the IgE dairy test results would be negative, despite having all the outward signs of a dairy allergy.

  When the three children who didn’t have positive results for an IgE dairy allergy come back for a visit, I’ll explain to the parents that even though the food allergy test was negative, I still suspect dairy is playing a role in their child’s issue (whether it is constipation, eczema, asthma, or chronic runny nose). We will agree on removing dairy for a short-term, doable, three-week trial while we closely monitored the child’s symptoms. (You will learn how to do a gradual, selective elimination diet and how to track your child’s symptoms in section II).

  Seeing these kids back for their follow-ups when they are three or four weeks into their dairy-free trial is like my little mini discotheques. Not only do the common inflammatory illnesses improve, but the kids’ nervous systems begin calming. Their parents tell me, “Ayisha is sleeping more soundly,” or “Ahmed is more cooperative, can handle transitions better, and is having fewer meltdowns when I ask him to clean up his room.” It took me several more years of studying nutrition and its many impacts to understand what was happening. It is one of the reasons it is extremely important to have concrete symptoms to track over time.

  Understanding the relationship between food and inflammation and repairing that relationship in a step-by-step manner are powerful tools for helping the body heal itself. Some of the specifics of this information can be hard to process, so I created the ginormous table near the end of this chapter to help explain the many ways food can cause inflammation in our bodies. Sadly, testing for these multifaceted signs of inflammation can be confusing.

  Before consulting the table, let’s get on the same page with vocabulary.

  FOOD ALLERGY

  A food allergy is an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food. Once the body is sensitized to the allergen, like peanuts, minimal exposure can trigger a powerful, profound, and fast inflammatory response. Histamine is released from mast cells and this can lead to hives, lip swelling, coughing, wheezing, vomiting, and trouble breathing. The reaction typically occurs within fifteen to thirty minutes of exposure, or it can be delayed up to twelve hours. It is serious and can be life-threatening.

  The following eleven foods account for about 90 percent of our food allergies and our food sensitivities. It doesn’t mean these foods are unhealthy. It just means that if your child has an issue that is food related, chances are, it will involve one of these.

  FOOD SENSITIVITY

  Any symptom perceived to be related to food is referred to as a food sensitivity. Since it is subjective, food sensitivity reactions (or non-reactions) can have a wide range of interpretations. This is why I created the healthy kids happy moms - SYMPTOM TRACKER, which you’ll find in section II. It is critical that we have concrete physical signs to monitor and track over time while we are changing your child’s diet and adding supplements.

  The best way of testing for a food sensitivity is to do a selective elimination diet, exactly what we will be doing with the HKHM program. We use our knowledge of the common foods that cause allergies and sensitivities and make some educated decisions about which foods to eliminate and in what order.

  FOOD INTOLERANCE (LACTOSE INTOLERANCE)

  A food intolerance is a non-immune-mediated adverse reaction to a food and includes conditions such as lactase deficiency (lactose intolerance). Lactose intolerance, dairy allergy, and dairy sensitivity often get confused because they have so many overlapping symptoms. I see this confusion so often that it deserves some further explanation.

  Lactose intolerance is when the body does not break down lactose, the sugar in dairy. It causes bloating, gas, nausea, and belly pain (see table on page 59 for symptoms). Dairy allergy is an immune-mediated reaction (which means the inflammation is triggered by cells that are part of the immune system) to one of the proteins in dairy, often casein. Casein and whey are the two main proteins in dairy. A dairy sensitivity is a non-immune-mediated reaction of the body to dairy. I will often see kids who have negative test results for a dairy allergy so parents will switch them to a lactose-free milk or formula, but their constipation, eczema, or recurrent ear or sinus infections persist. A true lactose enzyme deficiency at birth is genetic and extremely rare. Instead of being switched to a lactose-free product, these babies and young kids can do a three-week trial off casein and whey to see whether their symptoms are due to a sensitivity (which creates inflammation), to one of the proteins in dairy. Lactose-free formula and milk contains casein, so you want to use a formula that does not contain this protein. Kids one year and older can drink water or a non-dairy milk such as coconut, almond, or hemp milk.

  Although most of us can break down lactose in milk at birth, we begin to lose that ability around the age of three years. As we age, our ability to break down lactose continues to decline. Globally, about 70 percent of adults are not able to break down lactose (think about the bloating and gas that ensues if you drink a milkshake).2 The prevalence is even higher in people of South American, African, and Asian descent.

  CELIAC DISEASE

  This is an autoimmune disease in which the body reacts to gluten (the protein found in wheat, barley, and rye). It has a genetic component to it: once you have it, it is a lifelong condition, and you need to remain 100 percent off gluten as a new lifestyle.

  HISTAMINE INTOLERANCE

  Histamine is a chemical messenger in the body released when we are exposed to our allergens, both food and environmental. However, certain foods can also increase histamine release in the body, even when there is not a true allergy. The symptoms look very similar to a food allergy, but the inflammation is mediated in a different way. Some foods are simply rich in histamine, such as avocado. (I know, right? Can avocado really have any negative connotations?!)

  However, other foods can actually trigger histamine to be released. I have listed all of these out in the following table so you can keep them straight. Be particularly mindful of these foods if your child has eczema flares or if you often notice flushing on them (rosy cheeks, neck, or ears) at times when they are not playing hard. Excess histamine can play a role in both of those.

  For example, if your child has eczema and is already off the two big food triggers for eczema, dairy and eggs, review the list of high-histamine foods and see whether she is eating a lot of any one of them. You may just need to cut back on that food for a few weeks, see how her skin does and, then when you add it back in, monitor once again how the skin responds.

  As you read through this table, you will officially know significantly more about the many facets of food reactions than I did coming out of residency.

  CATEGORY FOOD ALLERGIES3 FOOD SENSITIVITIES CELIAC DISEASE4

  Symptoms Flushing, hives, itching, lip swelling, coughing, trouble breathing, wheezing, abdominal pain, nausea, vomiting, diarrhea, increased heart rate Runny nose, nasal congestion, abdominal pain, bloating, gas, loose stools or constipation, foggy brain, fatigue, skin rashes (eczema, bumps on the cheeks or back of arms), red ring around the anus, emotional outbursts, trouble focusing Weight loss or weight gain, poor growth in children
(short stature, failure to thrive), abdominal pain, bloating, gas, chronic loose stools or constipation, foggy brain, fatigue, trouble sleeping, joint or bone pain, iron-deficient anemia, B12 deficiency, menstrual irregularities, infertility, skin rash (dermatitis herpetiformis), behavior challenges, meltdowns or mood swings, trouble focusing, ADHD, anxiety, depression, seizures, numbness or tingling in the hands and feet

  Speed of Reaction Usually within fifteen minutes to two hours (but can be delayed up to twelve hours) Minutes to hours to days Symptoms can be extremely gradual and insidious. It often takes individuals years to get the right diagnosis (97 percent of people who have celiac disease do not know it, and the prevalence is 1 in 133)5

  Cells Involved Immune system IgE Non-immune system Immune system IgA and T-cells

  Food Examples Peanut

  Tree nuts

  Milk

  Egg

  Soy

  Wheat

  Corn

  Fish

  Shellfish

  Citric acid

  Sesame Milk

  Egg

  Soy

  Wheat (gluten)

  Corn

  Citric acid

  Sesame Gluten (the protein found in barley, wheat, and rye and many other processed foods)

  Testing Skin prick test

  or

  Bloodwork Selective elimination diet Blood test is controversial: many food sensitivity tests are available that test for IgG proteins to various foods.

  Some research suggests that elevated IgG4 proteins confer “tolerance” to a food

  Blood test for antibodies TTG (IgA, IgG)

  DGP (IgA, IgG)

  EMA(IgA)

  Endoscopy with biopsy of the small intestine to look for damage

  Must be eating gluten for the testing to be accurate

  Gold Standard Test Oral Food Challenge Selective elimination diet followed by reintroduction of the food (the HKHM program) Endoscopy with biopsy

  An Oral Food Challenge (OFC) is a medical procedure in which a food is eaten slowly, in gradually increasing amounts, under medical supervision, to accurately diagnose or rule out a true food allergy.

  TYPE OF REACTIONS FOOD INTOLERANCE6 HISTAMINE INTOLERANCE

  Symptoms/Disease Lactase deficiency (lactose intolerance): bloating, gas, abdominal pain, nausea with ingestion of dairy Allergic colitis: babies will present with blood in their stool

  Eosinophilic esophagitis (EE): discomfort in the upper chest and esophagus while eating; sometimes leads to avoiding eating

  Food protein-induced enterocolitis syndrome (FPIES): vomiting and diarrhea after ingesting certain foods in babies

  Similar to allergy symptoms: Flushing of the face, neck, ears, and body (can make eczema worse) Nausea

  Burning in the mouth

  Headache

  Faintness

  Abdominal cramps

  Bloating

  Diarrhea

  Wheezing or other breathing problems

  Swelling of the face and tongue

  Speed of Reaction Can be rapid or within hours Often within minutes to hours but can also persist if histamine levels remain elevated.

  Cells Involved Non-immune system Non-IgE mediated

  Cellular reaction

  Even though these issues seem similar to food allergies, most often the standard IgE food test results will be negative for cow’s milk even though it can be contributing to the inflammation

  Non-immune system When the diamine oxidase (DAO) enzyme which breaks down histamine in our bodies is not functioning properly

  Food Examples EE: common triggers Milk

  Eggs

  Soy

  Wheat

  Others

  FPIES: common triggers

  Milk

  Soy

  Rice

  Chicken

  Others

  Histamine-rich foods Spoiled fish

  Cured or smoked meats

  Smoked or canned fish

  Shellfish

  Leftover meats

  Fermented food (including beer)

  Vinegar

  Cow’s milk, yogurt

  Cheeses, aged cheeses

  Avocado

  Eggplant

  Spinach

  Foods that trigger histamine release

  Bananas

  Citrus fruits (lemons, oranges)

  Cherries

  Pineapple

  Strawberries

  Dried fruit

  Tomatoes

  Tree nuts

  Legumes (peanuts, beans)

  Chocolate

  Wheat germ

  Food dyes, additives, and some seasonings

  Alcohol

  Testing Doctor will decide based upon history, symptoms, and physical exam Possibly test stool for blood

  or

  perform endoscopy for abnormal cells (EE)

  Doctor will decide based upon history, symptoms, circumstances when the symptoms occur, and physical exam

  If I were to see Javier for the first time now, I would have much better and more concrete instructions to help his family get started. The steps outlined in section II of this book are the ones I developed over the past fifteen plus years of seeing hundreds of patients just like Javier.

  Today when I am evaluating a patient similar to Javier in my clinic, I do the IgE environmental allergy test when appropriate based upon symptoms. If I suspect a true food allergy, I generally refer to a pediatric allergist. If I don’t suspect a true food allergy, I test the child for celiac disease and then proceed with gradually removing dairy over three to four weeks and then removing gluten the same way.

  You must be eating gluten when testing for celiac disease. Once you remove it from your child’s diet for several months, or possibly even weeks, even if they have celiac disease, the antibodies may convert to being negative and you would get a false negative result. The child may actually have celiac disease, but the antibodies are not showing up because the food is no longer triggering a reaction in the body.

  Research in the field of nutrition is rapidly growing. I continue to expand my toolbox about how best to advise parents. One area that remains consistent is that certain foods drive inflammation. Inflammation hinders the immune system and also impacts many other systems of the body in addition to the gut, skin, lungs, sinuses, and ears. Typically, the kids who have the most profound improvements with nutrition changes are the ones who present with a constellation of inflammatory symptoms.

  As I used this concept that inflammation drives illness to look for the root cause of symptoms, it revolutionized my practice. I revised all my carefully crafted handouts not only to include the medications we might need for acute symptoms but also to educate families about how to decrease their exposure to specific allergens, how to look at nutrition to optimize natural anti-inflammatory foods, and how to remove foods that can be extremely pro-inflammatory. It continues to be eye-opening for me how environmental allergy symptoms improve when one cleans up the diet.

  TAKEAWAYS

  True food allergy is mediated by the immune system (like a peanut allergy). It’s diagnosed through a blood or skin prick test, patient history, and physical examination.

  Food sensitivity is an inflammation created by food, but not a true allergy. It’s diagnosed through a selective elimination diet.

  Celiac disease is an autoimmune allergy to gluten, the protein found in wheat, barley, and rye. It’s diagnosed through bloodwork or an endoscopy with biopsy. You can have celiac disease but not have an IgE wheat allergy.

  Food intolerance is inflammation along the GI tract which is mediated by food, but not a true allergy. Lactose intolerance is an example. It’s diagnosed in conjunction with your healthcare provider.

  Histamine intolerance is a reaction to foods that increase histamine levels, where the body is not efficiently able to break down and clear the histamine. It’s not a true allergy. It’s diagnosed in conjunction with your healthcare provider.
/>   Testing and diagnosing food reactions is not always straightforward. But as you begin to understand some of the subtle differences in how foods can affect us, you will understand why the HKHM program in section II is laid out the way that it is.

  CHAPTER 5

  overfed and undernourished

  THE FIRST TIME I became aware that artificial dyes and preservatives could impact children’s behavior and health was in 2010. Eleven-year-old Adam, who had ADHD, came to see me. His mother told me that when Adam ate food or candy with blue dye, he’d flap his hands like a child on the autism spectrum, and when he ingested caramel coloring, he would sniff his fingers.

  I had never heard of anything like this. I listened intently and then looked to see whether there was any research on this phenomenon.

  What was happening to Adam? Caramel coloring is made from food sources, such as wheat, barley, or milk, and milk is the most common source.1 Each of these individual foods are common allergens, so Adam could have had a sensitivity to one of these foods and not the caramel coloring itself.

  This mother was quite certain there was a direct correlation. Although it took her a while to figure it out, she had tested her hypothesis. She had given Adam those colorings on several occasions and watched his physical movements change. Adam was a gregarious young fella, and he understood how these ingredients impacted him. He explained that he would know he had accidentally ingested these ingredients because he would start flapping his hands or smelling his fingertips. He didn’t like feeling of being out of control of his body and was more than willing to avoid them.

  Mom had him on an all-organic diet free of artificial dyes, preservatives, gluten, and dairy prior to seeing me, and he was doing great. She brought him in for a well visit and as we talked through his history, she shared these things with me. I was blown away. Like Adam’s mother, many families can make nutrition changes at home and not need any further in-depth testing by a pediatrician.