A subset of walnut allergic adults is sensitized to walnut 11S globulin Jug r 4.

BACKGROUND: The role of sensitization to commercially available allergens of English walnut (Juglans regia) Jug r 1, 2 and 3 in walnut allergy has been previously investigated in walnut allergic adults and was unable to explain all cases of walnut allergy. OBJECTIVES: Identify recognized walnut allergens, other than the ones previously investigated (Jug r 1-3), in walnut allergic adults and determine the sensitization frequency and diagnostic value. METHODS: Three different in-house walnut extracts were prepared and analysed on SDS-PAGE blots to identify allergenic walnut proteins. Immunoblots and immunoprecipitation, followed by LC-MS analysis, were performed to screen for, and confirm, IgE binding to walnut allergens in selected walnut allergic adults. In a cohort of 55 walnut challenged adults, including 33 allergic and 22 tolerant, sensitization to native and recombinant walnut allergen Jug r 4 was assessed using immunoblotting and immuno-line blot (EUROLINE), respectively. RESULTS: Screening of sera of 8 walnut allergic adults identified Jug r 4 as an allergen in our population. In the total cohort of 55 subjects, 5 were positive for Jug r 4 on immunoblot and 10 on EUROLINE. All but one EUROLINE positive subject had a positive food challenge (sensitivity 27%, specificity 95%, PPV 90%, NPV 47%). All 5 subjects positive on immunoblot were also positive on EUROLINE. LC-MS analysis showed a lack of Jug r 4 in the ImmunoCAP extract. Co-sensitization to other 11S albumins (eg hazelnut Cor a 9) was common in Jug r 4 sensitized subjects, potentially due to cross-reactivity. CONCLUSIONS: Walnut 11S globulin Jug r 4 is a relevant minor allergen, recognized by 27% of walnut allergic adults. It has a high positive predictive value of 90% for walnut allergy. Specific IgE against Jug r 4 occurred mostly with concomitant sensitization to other walnut components, mainly Jug r 1.

Can we identify patients at risk of life-threatening allergic reactions to food?

Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.

Frequency, severity and causes of unexpected allergic reactions to food: a systematic literature review.

Food allergic patients have to deal with an avoidance diet. Confusing labelling terms or precautionary labels can result in misinterpretation and risk-taking behaviour. Even those patients that strictly adhere to their diet experience (sometimes severe) unexpected allergic reactions to food. The frequency, severity and causes of such reactions are unknown. The objective of this review was to describe the frequency, severity and causes of unexpected allergic reactions to food in food allergic patients aged > 12 years, in order to develop improved strategies to deal with their allergy. A systematic review was carried out by two researchers, in six electronic databases (CINAHL, Cochrane, EMBASE, Medline, Psychinfo and Scopus). The search was performed with keywords relating to the frequency, severity and causes of unexpected allergic reactions to food. This resulted in 24 studies which met the inclusion criteria; 18 observational and six qualitative studies. This review shows that knowledge about the frequency of unexpected reactions is limited. Peanut, nuts, egg, fruit/vegetables and milk are the main causal foods. Severe reactions and even fatalities occur. Most reactions take place at home, but a significant number also take place when eating at friends' houses or in restaurants. Labelling issues, but also attitude and risky behaviour of patients can attribute to unexpected reactions. We conclude that prospective studies are needed to get more insight in the frequency, severity, quantity of unintended allergen ingested and causes of unexpected allergic reactions to food, to be able to optimize strategies to support patients in dealing with their food allergy. Although the exact frequency is not known, unexpected reactions to food occur in a significant number of patients and can be severe. For clinical practice, this means that patient education and dietary instructions are necessary.

Objective eliciting doses of peanut-allergic adults and children can be combined for risk assessment purposes.

BACKGROUND: To improve food labelling strategies, information regarding eliciting doses (EDs) and the effect of patient characteristics on these EDs is necessary. OBJECTIVE: To establish EDs for objective and subjective symptoms and analyse the effect of sensitization levels and other patient characteristics on threshold distribution curves (TDCs). METHODS: Threshold data from 100 adults and 262 children with a positive food challenge were analysed with interval-censoring survival analysis (ICSA) and fitted to a TDC from which EDs could be extracted. Possible influencing factors were analysed as covariates by ICSA. A hazard ratio (HR) was calculated in case of a significant effect. RESULTS: TDCs for both objective and subjective symptoms were significantly different between adults and children (P < 0.001). Objective ED05 values, however, were comparable (2.86 mg peanut protein in adults and 6.38 mg in children). Higher levels of sIgE to Ara h 2 and peanut extract were associated with a larger proportion of patient groups reacting to a dose increase with objective symptoms (adults and children) or subjective symptoms (adults, in children a trend). Age had a similar effect in children (HR 1.05 for objective symptoms and 1.09 for subjective symptoms). Gender had no effect on TDCs. CONCLUSION AND CLINICAL RELEVANCE: Subjective and objective TDCs were different between adults and children, but objective ED05 values were comparable, meaning that threshold data from children and adults can be combined for elaboration of reference doses for risk assessment. Higher sIgE levels to Ara h 2 and peanut extract were associated with a larger proportion of both patient groups to react to a certain dose increase.

Unintended allergens in precautionary labelled and unlabelled products pose significant risks to UK allergic consumers.

BACKGROUND: Allergens in food may pose a risk to allergic consumers. While there is EU regulation for allergens present as an ingredient, this is not the case for unintended allergen presence (UAP). Food companies use precautionary allergen labels to inform allergic individuals of a potential risk from UAPs. This study investigates the risk of an allergic reaction within the milk-, wheat-, hazelnut- and peanut-allergic populations when ingesting UK foods across multiple product categories with and without precautionary allergen labelling. METHODS: Allergen risk assessment using probabilistic techniques enables the estimation of the residual risk after the consumption of a product that unintentionally contains an allergen. RESULTS: Within this selection of UK products, the majority that tested positive for an allergen contained a concentration of allergen predicted to cause a reaction in >1% of the allergic population. The concentrations of allergens measured were greater than the VITAL(®) 2.0 action levels and would trigger precautionary allergen labelling. This was found for products both with and without precautionary allergen labelling. CONCLUSIONS: The results highlight the need for the food industry and regulators to adopt a transparent, risk-based approach for the communication of the risk associated with potential cross-contact that could occur in the processing facility or production chain.

Precautionary allergen labelling: perspectives from key stakeholder groups.

Precautionary allergen labelling (PAL) was introduced by the food industry to help manage and communicate the possibility of reaction from the unintended presence of allergens in foods. However, in its current form, PAL is counterproductive for consumers with food allergies. This review aims to summarize the perspectives of all the key stakeholders (including clinicians, patients, food industry and regulators), with the aim of defining common health protection and risk minimization goals. The lack of agreed reference doses has resulted in inconsistent application of PAL by the food industry and in levels of contamination that prompt withdrawal action by enforcement officers. So there is a poor relationship between the presence or absence of PAL and actual reaction risk. This has led to a loss of trust in PAL, reducing the ability of consumers with food allergies to make informed choices. The result has been reduced avoidance, reduced quality of life and increased risk-taking by consumers who often ignore PAL. All contributing stakeholders agree that PAL must reflect actual risk. PAL should be transparent and consistent with rules underpinning decision-making process being communicated clearly to all stakeholders. The use of PAL should indicate the possible, unintended presence of an allergen in a consumed portion of a food product at or above any proposed action level. This will require combined work by all stakeholders to ensure everyone understands the approach and its limitations. Consumers with food allergy then need to be educated to undertake individualized risk assessments in relation to any PAL present.

Application of scientific criteria to food allergens of public health importance.

Scientific criteria for identifying allergenic foods of public health importance (Björkstén, B., Crevel, R., Hischenhuber, C., Løvik, M., Samuels, F., Strobel, S., Taylor, S.L., Wal, J.-M., Ward, R., 2008. Criteria for identifying allergenic foods of public health importance. Regulatory Toxicology and Pharmacology 51(1), 42-52) have been further refined to incorporate an assessment of the strength of available scientific evidence (van Bilsen, J.H., Ronsmans, S., Crevel, R.W., Rona, R.J., Przyrembel, H., Penninks, A.H., Contor, L., Houben, G.F., 2011. Evaluation of scientific criteria for identifying allergenic food of public health importance. Regulatory Toxicology and Pharmacology 60, 281-289). A multi-disciplinary group was invited to critically test the refined approach. They independently evaluated selected publications on coconut, soy and/or peanut allergy, scored them using the newly developed level of evidence criteria, and debated proposed approaches for combining and utilising the scores to measure the overall impact of an allergen in public health impact assessments. The evaluation of selected publications using the modified criteria produced a relatively consistent result across the experts. These refined criteria were judged to be a way forward for the identification of allergenic foods of public health importance, and for prioritisation of allergen risk management and future data gathering. The debate to combine available evidence when assessing whether an allergenic food is of sufficient public health importance to warrant active management led to proposals on how to weight and combine evidence on allergen severity, potency and prevalence. The refined criteria facilitate a debate to find a meaningful sequence of steps to summarise the available information in relation to a food allergen.

Evaluation of scientific criteria for identifying allergenic foods of public health importance.

Identification of allergenic foods of public health importance should be based on well-defined criteria. Björkstén et al. (2008) proposed that the criteria should assess the evidence for an IgE mechanism, the reaction, the potency and the severity of the effect of the food and its prevalence. This study evaluated the application of the proposed criteria based on published reports. Publications were selected from two databases to test whether the descriptions for ranking the level of evidence for each criterion were unambiguous and covered the full range of levels of evidence regarding seven foods, five known to be allergenic and two negative controls. The options available to rank the quality of evidence were appropriate but needed refinement to improve clarity and conceptual value. The criteria were helpful to assess known IgE-dependent allergens, and to exclude the non-allergenic substances. The criteria framework discriminated between papers with high, moderate and low quality of evidence. The advantage of using the proposed criteria is to make the decision-making process and rationale explicit. The framework helps to identify gaps in knowledge and to uncover the level of heterogeneity of the evidence thus guiding research and providing a basis for sound risk management decisions.

Prevention of work-related airway allergies; summary of the advice from the Health Council of the Netherlands.

The Health Council of the Netherlands published a report in which the best procedure and method for recommending health-based occupational exposure limits (OELs) for inhaled allergens were identified by evaluating the scientific state of the art. Many respiratory disorders in the workplace arise from inhalation of substances which can cause allergy. To protect workers against respiratory allergy, various preventive measures are taken, one of them being reduction of exposure by setting legally binding standards. These are based on health-based OELs that specify a level of exposure to an airborne substance, a threshold level, below which it may reasonably be expected that there is no risk of adverse health effects. The Council is of the opinion that an OEL should prevent against allergic sensitization, as sensitization plays a crucial biological role and is a prerequisite for the development of allergy. Furthermore, the Council considers it most likely that the exposure level below which no allergic sensitization develops for most allergens is so low, that OELs are difficult to set with the current knowledge and technical feasibilities. An alternative approach is to accept exposure, which carries a small predefined risk in developing allergic sensitization. In addition, it is worth considering periodic screening of exposed workers on allergic sensitization, because timely intervention can prevent worse. The feasibility of periodic screening and what else is needed to comply with the most important criteria, should however be judged case-by-case.

Probabilistic risk assessment model for allergens in food: sensitivity analysis of the minimum eliciting dose and food consumption.

Previously, TNO developed a probabilistic model to predict the likelihood of an allergic reaction, resulting in a quantitative assessment of the risk associated with unintended exposure to food allergens. The likelihood is estimated by including in the model the proportion of the population who is allergic, the proportion consuming the food and the amount consumed, the likelihood of the food containing an adventitious allergen and its concentration, and the minimum eliciting dose (MED) distribution for the allergen. In the present work a sensitivity analysis was performed to identify which parts of the model most influence the output. A shift in the distribution of the MED reflecting a more potent allergen, and an increase in the proportion of the population consuming a food, increased the number of estimated allergic reactions considerably. In contrast, the number of estimated allergic reactions hardly changed when the MEDs were based on a more severe response, or when the amount of food consumed was increased. Development of this work will help to generate a more accurate picture of the potential public health impact of allergens. It highlights areas where research is best focused, specifically the determination of minimum eliciting doses and understanding of the food choices of allergic individuals.

Approaches to assess IgE mediated allergy risks (sensitization and cross-reactivity) from new or modified dietary proteins.

The development and introduction of new dietary protein sources has the potential to improve food supply sustainability. Understanding the potential allergenicity of these new or modified proteins is crucial to ensure protection of public health. Exposure to new proteins may result in de novo sensitization, with or without clinical allergy, or clinical reactions through cross-reactivity. In this paper we review the potential of current methodologies (in silico, in vitro degradation, in vitro IgE binding, animal models and clinical studies) to address these outcomes for risk assessment purposes for new proteins, and especially to identify and characterise the risk of sensitization for IgE mediated allergy from oral exposure. Existing tools and tests are capable of assessing potential crossreactivity. However, there are few possibilities to assess the hazard due to de novo sensitization. The only methods available are in vivo models, but many limitations exist to use them for assessing risk. We conclude that there is a need to understand which criteria adequately define allergenicity for risk assessment purposes, and from these criteria develop a more suitable battery of tests to distinguish between proteins of high and low allergenicity, which can then be applied to assess new proteins with unknown risks.

Risk assessment and food allergy: the probabilistic model applied to allergens.

In order to assess the risk of unintended exposure to food allergens, traditional deterministic risk assessment is usually applied, leading to inconsequential conclusions as 'an allergic reaction cannot be excluded'. TNO therefore developed a quantitative risk assessment model for allergens based on probabilistic techniques resulting in a more exhaustive risk assessment and more detailed information. By now, this approach is recognized as the future approach in allergen risk assessment. A case study (hazelnut proteins in chocolate spread) is presented as a proof of concept.

Immunotoxicity of the colour additive caramel colour III; a review on complicated issues in the safety evaluation of a food additive.

Food additives can be regarded as the safest constituents of our daily food. Nevertheless, complicated issues with respect to their safety evaluation do also occur. In this review paper, some of these issues are illustrated by the description and evaluation of the research on the immunotoxicity of the food additive Caramel Colour III. Caramel Colour III is commonly used as a color additive in many products for human consumption. Toxicity studies conducted in the seventies demonstrated that administration of Caramel Colour III can cause a reduction in total white blood cell counts in rats, due to reduced lymphocyte counts. Studies reviewed in this paper demonstrated several other effects of Caramel Colour III on the immune system of rodents, including disturbed immune functions and changed resistance in infection models. In addition, studies in rats demonstrated that most of the effects occur only when the animals are fed a diet low in vitamin B6. The imidazole derivative 2-acetyl-4(5)-(1,2,3,4-tetrahydroxy-butyl)-imidazole (THI) was found to be responsible for the immunotoxicity. Issues such as the mechanism of action of THI and the role of vitamin B6 are discussed. Finally, the results of a human intervention study and the observed effect levels of THI in rats are discussed in terms of safety of the use of Caramel Colour III in our daily food supply.

The SCID-hu mouse as a tool in immunotoxicological risk assessment: effects of 2-acetyl-4(5)-tetrahydroxybutyl-imidazole (THI) and di-n-butyltin dichloride (DBTC) on the human thymus in SCID-hu mice.

SCID mice engrafted with human fetal thymus and liver tissue fragments (SCID-hu mice) are currently considered as a new tool in human immunotoxicological risk assessment. Testing of various immunotoxicants exerting thymotoxicity via different intrathymic target cell types is necessary for validation of this model. Therefore, SCID-hu mice were exposed to 2-acetyl-4(5)-(1,2,3,4-tetrahydroxybutyl)-imidazole (THI), the immunotoxic component in the food additive, Caramel Colour III, or the organotin compound, di-n-butyltin dichloride (DBTC). Histopathological examination of the human thymus grafts of SCID-hu mice either exposed to THI or to DBTC showed a reduction in the relative size of the thymus cortex, an effect also described in rodents. These results indicate that the human thymus is a target for the immunotoxic action of both THI and DBTC. In addition, they indicate the promising potential of the SCID-hu mouse model as a tool for human immunotoxicological risk assessment.

Effects of saponins and glycoalkaloids on the permeability and viability of mammalian intestinal cells and on the integrity of tissue preparations in vitro.

The effects of potato and tomato glycoalkaloids and a saponin mixture from Gypsophila were investigated in cytotoxicity studies (neutral red uptake, mitochondrial MTT reduction and release of lactate dehydrogenase), using cultured cell lines of rat and human intestinal mucosal epithelium. Experiments to assess the effects of these compounds on the integrity of the intestinal epithelium were also carried out using preparations of isolated rat jejunum in vitro. By investigating the effect of these compounds on cultured cells and on intestinal tissue preparations, changes in membrane integrity, as evidenced by lactate dehydrogenase leakage in cell culture, could be confirmed in a system more relevant to the whole gut. Of the compounds tested, alpha-tomatine was consistently the most potent in all tests, and indications of a synergistic effect on membrane depolarization were observed between alpha-chaconine and alpha-solanine at total glycoalkaloid concentrations of less than 1 mM (< 0.86 mg/ml), with an optimum when the former comprised 25% of the mixture. An increase in the apparent permeability of the brush border was observed at sublethal concentrations of the compounds, and this may have important implications with respect to enhanced uptake of macromolecules, such as allergens, whose passage through the epithelium is normally somewhat restricted.

Humoral and cellular immune responses in different rat strains on oral exposure to ovalbumin.

No adequate enteral sensitization models are available to study food allergy and allergenicity of food proteins. Using a previously described oral sensitization protocol to sensitize Brown Norway rats (BN) to food proteins, the influence of genetically-based strain-specific characteristics of the immune system on the outcome of oral sensitization studies was investigated. BN, Hooded Lister (HL), Piebald Virol Glaxo (PVG) and Wistar rats were daily administered 1 mg of ovalbumin (OVA) by gavage dosing for 42 days without the use of an adjuvants. The highest OVA-specific IgG responses were detected in the BN rats followed by Wistar, HL and PVG rats. OVA-specific IgE responses were only detectable in the BN rats. The cellular immune response was examined by determination of delayed-type hypersensitivity (DTH) reactions in the animals. The response was most pronounced in the HL and Wistar rats. PVG and BN rats showed comparable DTH responses but the responses were significantly weaker than those observed in HL and Wistar rats. It was concluded that the genetic make-up of different rat strains influences the outcome of oral sensitization studies. In addition, using the described oral sensitization protocol, the BN rat seems to be the most suitable strain for inducing oral sensitization.

Effects of Caramel Colour III on the number of blood lymphocytes: a human study on Caramel Colour III immunotoxicity and a comparison of the results with data from rat studies.

Administration of the colour additive Ammonia Caramel Colour (Caramel Colour III) to rats has been associated with decreased lymphocyte counts, specifically in rats fed a diet low in vitamin B6. This effect is rapidly reversible and is caused by an imidazole derivative (THI) in Caramel Colour III. In the present paper, the conduct of a human study with Caramel Colour III is outlined and the results of blood lymphocyte counts are presented. No decrease in the number of blood lymphocytes occurred in marginally vitamin B6-deficient humans who consumed Caramel Colour III at the acceptable daily intake level (200 mg/kg body weight/day) for 7 days. These data are discussed in relation to the effects of Caramel Colour III and THI on blood lymphocyte numbers in rats.

Effects of the colour additive caramel colour III on the immune system: a study with human volunteers.

Administration of the colour additive Caramel Colour III to rats has been associated with decreased numbers of lymphocytes and several other changes in the immune system, as well as in immune function parameters, specifically in animals fed a diet with a relatively low vitamin B6 content. The effects are caused by the imidazole derivative 2-acetyl-4(5)-tetrahydroxybutylimidazole (THI). Caramel Colour III is commonly used in food products such as bakery products, soya-bean sauces, brown sauces, gravies, soup aromas, brown (dehydrated) soups, brown malt caramel blend for various applications, vinegars and beers, and effects in humans on dietary intake cannot be excluded. Elderly male volunteers with a marginal deficit in vitamin B6 were considered a relevant and potentially sensitive group to study possible effects of Caramel Colour III on blood lymphocyte numbers (total and within subsets) or on proliferative responses of lymphocytes to mitogenic stimulation. In addition, several other haematological parameters, as well as serum immunoglobulin levels and immunoglobulin production in vitro by pokeweed mitogen-stimulated mononuclear blood cells were studied. The results of this double-blind intervention study demonstrated that in a selected test group of apparently healthy elderly male volunteers with a biochemically marginally deficient vitamin B6 status, Caramel Colour III containing 23 (commercial sample) or 143 (research sample) ppm THI and administered at the level of the current acceptable daily intake of 200 mg/kg body weight/day for 7 days did not affect any of the factors investigated.

Food allergy: predictive testing of food products.

Food allergy is a substantial cause of distress in humans. Several biotechnological techniques can be applied to reduce the antigenicity of food proteins to produce for instance hypoallergenic infant formulas. Biotechnological techniques synthesizing new proteins or new biological varieties for applications in food are also available. For such biotechnologically for derived protein products (novel foods), allergenicity may also pose a major concern. For safety reasons, it is of importance to evaluate the residual antigenicity of modified protein products, to screen for possible cross-reactivity to prevent reactions in previously sensitized individuals, and to test for sensitizing properties of new and/or modified protein products. Besides physico-chemical and immunochemical analyses, several in vitro and in vivo bioassays may be applied in studying the antigenic or allergenic properties of (new or modified) food proteins. In this paper, an overview of several available assays and new developments for determining the antigenic or allergenic properties of dietary proteins, as well as their possible applications and limitations is presented. Special attention is paid to the role of the gastro-intestinal tract physiology in food allergy and in the evaluation of the allergenic potential of food proteins and to the possible applications of animal models in food allergy research and in the evaluation of the allergenicity of food proteins.

[Food additives as a cause of medical symptoms: relationship shown between sulfites and asthma and anaphylaxis; results of a literature review]. / Voedseladditieven als oorzaak van medische klachten: alleen voor sulfiet verband met astma en anafylaxie aangetoond; resultaten van een literatuuronderzoek.

OBJECTIVE: To determine if a causal connection exists between food additives and various medical complaints. DESIGN: Literature study. METHOD: Medline over the period January 1966-January 1999 was searched for articles on the following substances not containing protein and lactose: monosodium glutamate (MSG), sulfites, azo-dyes (tartrazine, sunset yellow, azorubin, amarant, cochineal red), benzoates, sorbates, butylated hydroxyanisole/butylated hydroxytoluene (BHA/BHT), parabens, cinnamon and vanilla, in combination with key words regarding food and side effects. Of those studies purporting to demonstrate an effect, only double-blind randomized placebo-controlled studies with oral challenge were assessed further, unless the complaint was anaphylaxis. Of studies not demonstrating an effect the design was assessed. RESULTS: Only for sulfites as causative agents of asthma and anaphylaxis, methodologically adequate studies demonstrating a causal connection could be found. For azo-dyes, benzoates, MSG, sorbates and BHA/BHT, no link with medical symptoms was demonstrable. For parabens, cinnamon and vanilla there were insufficient or inadequate data to justify a conclusion.