I am really challenging myself as I write on this topic of “food intolerance” and “food allergy.” and comment on the latest trend of “IgG (immunoglobulin G) Food Intolerance Tests.”1 Why write about a subject for which I am definitely not an “expert”? It is precisely the disconnect between the new industry of food intolerance testing, the fast-paced expansion of “integrative medicine”, and the traditional academic medical and research environment in which I live, practice, and care for pediatric patients that mandate an honest discussion. Let’s back up to my medical school years,1992-1996, my lecture courses in organic chemistry, pharmacology, physiology, followed by clinical rotations in internal medicine, pediatrics, amongst all other core and subspecialty rotations did not ever include “food intolerance.” I distinctly remember learning about “anaphylaxis”, defined as a severe, potentially life-threatening allergic reaction which can occur within seconds or minutes of exposure to something you’re allergic, such as peanuts. This is so widely respected such that any flight on Southwest airline, if a passenger has a declared peanut allergy then you can be sure not a single packet will be served during the snack service. Anaphylaxis describes the cascade of immune system reactions that can lead one into “shock” where there can be life-threatening changes in blood pressure, rash, swelling of mucous membranes that can lead to difficulty breathing. It can occur with medications and venom from bee sting or insects. Generally, severe positive reaction on skin prick or intradermal skin test is what results in recommendation of caretakers having an “Epi-pen” for immediate treatment should unintended exposure occur.
This blog is not about anaphylaxis. It’s easy to know when someone has such a reaction. What I am writing about is the mystery of food allergies, “sensitivity,” and/or “intolerance.” If your child eats something which immediately causes rash and/or lip swelling, no one will likely argue that he/she is “allergic” to that item and caretakers will quickly make sure the child avoids that. Let’s introduce the word “immunoglobulin,” which are secreted by a type of cell, the plasma cell, and function as antibodies in our immune system. There are 5 classes, IgA, IgD, IgE, IgG, and IgM. The most relevant to my blog on food allergy/sensitivity are IgG and IgE. Anaphylaxis and immediate allergic reactions are due to IgE reactions. Traditional blood tests to look for possible food and environmental allergies have focused on levels of IgE in the blood. So common food items which children may test allergic to include dairy, eggs, tree nuts, peanuts, soy, and now wheat.
However, the most recent buzz has been all about IgG, which may indicate food “sensitivity” or intolerance. This is not an allergic reaction but rather a collection of diverse symptoms such as bloating, abdominal pain, gas, diarrhea, constipation, headache, dizziness, mental fog, acne, eczema, join pain, etc. You will learn much more about this from naturopathic doctors, doctors in the field of integrative medicine, and even chiropractors than MDs like me. Let’s pick Celiac Disease as an example, which I learned about in medical school. This is a condition due to immune reaction from exposure to the protein “gluten,” found in bread, pasta, pizza crust, cakes, cookies, cereal, and all (likely yummy) foods made with the grains wheat and wheat based fours, barley, and rye. I simply do not recall meeting more than 1-2 adults and children who carried such a diagnosis during my 2 years of clinical rotations! But the world I practice in now, is full of otherwise healthy children whose mothers come see me for ear, nose, and throat symptoms and share with me that their child is on a “gluten-free” diet. This intrigues me as a mother and a physician. I feel compelled to then ask briefly how the child received that diagnosis and what the parents are doing. Often these children have been seen by an allergist and received some type of testing, but there are certainly others in whom the parents themselves have been “diagnosed,” or based on parent’s experience that their symptoms are better through elimination of such items. As a mother and physician, I have great empathy for children who have tested positive on blood tests and/or have had intestinal biopsy leading to such a diagnosis. What a challenge to brace a life of making sure your child is not eating anything containing gluten as well as plan and make meals for the entire family while considering the needs of the one with issues! When mothers ask me what I think, I simply share with them what I have read and heard, but apologize for disappointing them when I can’t address whether they should have put their child on elimination diets or other diet restrictions because of a belief of food sensitivities or intolerance.
Studies have reported an increase in the number of adults and children with celiac disease and intolerance of gluten.2 Simply google GMO (genetically modified organism) and gluten intolerance to read many articles explaining the link.3 Jeffrey Smith, an author who produced and directed the documentary Genetic Roulette: The Gamble of Our Lives, focuses on the rise in digestive disorders in recent decades in parallel with rise in foods containing GMOs in the U.S.4,5 With so much compelling social dialogue by those passionate about nutrition, organic farming, information and evidence concerning how advances in food biotechnology may be of significant risk to human health, why is there still confusion about who is allergic or intolerant to what? I searched PubMed, a bibliographic database produced by the National Center for Biotechnology Information and part of the National Library of Medicine, which comprises of more than 22 million citations and where we physicians and researchers go to in order to find scholarly publications for research on just about any topic. Not surprising to me, when I search “genetically modified organisms” AND “celiac”, I found only 4 citations, all basic science research and none in clinical medical journals. When searching “GMOs” AND “gluten”, I found 93 articles but all published journals that doctors like me would never read, like Plant Biotechnology, Agricultural Food Chemistry, Experimental Botony, Transgenic Research, just to name a few. A busy doctor and surgeon like me is barely able to keeping up on current research on topics involving ENT and pediatric ENT problems, so unless I am personally compelled or interested on the topic, I am unlikely to be aware of the most detailed and cutting-edge information about agriculture and biotechnological research. Furthermore, no matter how promising lab research data may be, even in animal models, we must recognize the gap between basic science research findings and translating that into clinical practice. Translational research is exactly the goal of the National Institutes of Health, to help apply discoveries in lab research to studies in humans as well as use scientific evidence to adopt best practices in all areas of medicine in the community. Highly variable personalized opinions in the practice of medicine is no longer acceptable standard of care in medicine, and our patients deserve better.
Back to the discrepancy between how I am trained to care for patients, and the realities of the challenges of delivering effective care to my patients today. We are overwhelmed with too much information, and know both too much and too little, at the same time, to know exactly what to do for our patients. Referring back to my first reference, there is lack of published clinical trials that validate the current IgG blood tests to support their use for accurate diagnosis of food-related symptoms and food allergy/intolerance. In fact, it turns out that the degree of sensitivity or intolerance to a food item, mild, moderate, or severe, does not actually correlate to patient symptoms. This makes interpreting test results incredibly difficult. If it’s difficult to make sense of individual test results and there are yet specific and conclusive patterns which are observed in large populations, how can we actually apply treatment plans for entire or part of any populations? For a clinically trained physician and surgeon like myself, I simply can’t rely on any holistic or integrative approaches I was not trained in or don’t have the support of well-designed scientific research to back up what I recommend to patients and their families. You can read the exact statements by established national and international societies of allergy, asthma, immunology, and see what they all have in common, that specific IgG-antibodies in serum does not correspond to oral food challenges, and while it does play a role in the allergic response, there is no evidence to suggest that it has a diagnostic value in predicting food allergens. That does not stop the industry to push for the practice of individualized testing. In the name of integrative medicine, there will be continued expansion of more products, services, practitioners, and advertised benefits of IgG food allergy testing. I am neither supporting nor condemning IgG food allergy testing, but simply sharing with you the issues surrounding this topic. The reason that we will all continue to hear and see more on this topic, is because adults have learned to demand more than medical and surgical treatments as the solutions to their wellness. The age of immediate and massive information at our hands has made us as a society mandate that our health care providers learn, know, and understand how to apply the latest in all areas of life and science into our traditional practice of medicine as we were taught it. The only way I can do so is in the context of a team-approach, I simply do not have the time, expertise, or ability to extract all available information and make it a perfectly individualized treatment plan that guarantees success. The best that I have been able to do has been sharing my repeated observations about how excessive dairy and sugar, as well as late night eating, is likely correlated with the chronic ENT symptoms that I have seen. The best that I have been able to do, is to empower families and increase awareness of how important diet is in our children’s health, even if you do not go into the details of scientific research or understand everything about GMOs. I believe physicians like myself, in order to embrace the challenge of caring for my patients in the 21st century, must function in a team. I am looking for the best team of others who believe like I, that good diet and dietary habits, impacts EVERY aspect of our children’s health, and even as a surgeon, I know that I can make the most difference each and every day by incorporating discussions about how to help our children live in A Healthier Wei.