Transcript New Directions Food labelling and Allergy Prevention

Avoiding the
Offending Allergen
Ingredient Lists and Labelling Laws
Canada’s Food Labelling Laws
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On February 16th 2011 Health Canada
Published Amendments to the Food Allergen
Labelling Regulations in Canada Gazette, Part
II (CGII)
The new Regulations were designed to
enhance labelling requirements for specific
priority allergens, gluten sources and added
sulphites in prepackaged foods sold in Canada
The new food allergen labelling regulations
came into force on August 4, 2012
http://www.hc-sc.gc.ca/fn-an/label-etiquet/allergen/index-eng.php
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Reasons for the New Laws
Health Canada's policy for enhancing the
protection of food-allergic consumers in
Canada is based on two guiding principles:
 Prevent the inadvertent consumption of
undeclared allergens by sensitive consumers
 Enable a variety of safe and nutritious food
choices for the allergic consumer
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Ten Priority Allergens
The list of priority allergens now includes:
 Peanuts
 Tree nuts (almonds, Brazil nuts, cashews, hazelnuts,
macadamia nuts, pecans, pine nuts, pistachios,
walnuts)
 Milk
 Eggs
 Seafood (fish, crustaceans, shellfish)
 Soy
 Wheat
 Sesame seeds
 Mustard
 Sulphites
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Labelling of "hidden" priority
allergens
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Previously, food labels did not have to declare when a
priority allergen was used to make an ingredient like
spices or flavours
Now, labels on products will have to let consumers
know when these allergens are in the product, either
in the ingredient list or in a "contains" statement
The allergen may appear in the ingredient list
Components of an ingredient like spices may be in
brackets
And/or the allergen may appear in a "contains"
statement after the ingredients, like "Contains: XX”
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Plain Language
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Previously a number of names for an ingredient,
some of which were unfamiliar to the general public,
could appear on labels
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With the new food labels, companies will have to use
commonly understood names for the priority
allergens
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E.g. “casein”, whey”, “lactalbumin”, “lactose”, etc
E.g. for the ingredients above, “milk” must appear on the
label
The names, such as "wheat" or "milk," will have to be
used either in the ingredient list or in the "contains"
statement
Some manufacturers include them in both
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Precautionary Statements
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Previously a number of precautionary statements
appeared on labels, eg:
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May contain trace amounts of [X]
Produced on shared equipment with [X]
Manufactured in a facility that also manufactures [X]
Health Canada and the CFIA are recommending that
food manufacturers and importers begin to use only
one precautionary statement on food labels:
"may contain [X]"
where X is the name by which the allergen is commonly
known
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“Natural” Foods
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Nature", "natural", "Mother Nature", "Nature's Way"
are terms often misused on labels and in
advertisements
“Advertisements should not convey the impression
that "Nature" has, by some miraculous process, made
some foods nutritionally superior to others or has
engineered some foods specially to take care of
human needs”
Some consumers may consider foods described as
"natural" of greater worth than foods not so described
http://www.inspection.gc.ca/english/fssa/labeti/guide/ch4ae.shtml
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Manufactured Foods
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Foods or ingredients of foods submitted to processes
that have significantly altered their original physical,
chemical or biological state should not be described
as "natural“
 E.g: the removal of caffeine from coffee
A natural food or ingredient of a food is not expected
to contain, or to ever have contained, an
added vitamin, mineral nutrient, artificial flavouring
agent or food additive.
A natural food or ingredient of a food does not have
any constituent or fraction thereof removed or
significantly changed, except the removal of water
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“Natural” Additives
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Some food additives, vitamins and mineral nutrients
may be derived from natural sources
Some of these additives may be regarded as natural
ingredients, in which case the acceptable claim would
be that this food contains "natural ingredients“
If the additive is derived from a priority allergen, the
allergen must be listed on the label
Note that while the ingredient can be described as
"natural", the food itself cannot, since it contains an
added component.
The list of ingredients of such foods must declare
acids, bases, salts or sweeteners which are present by
their proper common names
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Food Additive Ingredients
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Food additives are considered ingredients in any prepackaged food and must be:
 Included in the ingredients’ list
 Listed by the common name associated with the
active ingredient in the preparation
In general, food ingredients are listed in descending
order of proportion by weight
However, food additives, spices, seasonings, herbs
(except salt), natural and artificial flavours, flavour
enhancers, vitamins and mineral nutrients and their
derivatives and salts, may be placed at the end of the
ingredients list in any order
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Food Additives
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Foods meant for human consumption may
contain additives under the GRAS (generally
recognized as safe) designation
Level of food additives may be allowed
according to “good manufacturing practices”:
Amount determined by standards for the product
 E.g: annatto is added to butter to the amount
required to bring it to an established standard
yellow colour
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Levels of additives permitted in
foods
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Others will have upper limits determined for
each food type, e.g.
Benzoic acid in jams and juices not to exceed
1,000 ppm
 Nitrites in preserved meats not to exceed 200 ppm
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Whatever the limit, the presence of the
additive will be indicated on the food label
http://www.hc-sc.gc.ca/fn-an/securit/addit/list/11-preserv-conserv-eng.php
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Food Colours
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Three colours must be listed by name:
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Annatto
Allura red
Sunset yellow
One or more of the other allowed food colours may
be listed in the ingredients simply as “colour”
Regulations provide food manufacturers with the
choice of declaring added colours by either their
common name or simply as "colour"
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Artificial Food Dyes Permitted in
Canada
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Alkanet
Allura red
Aluminum metal
Amaranth
Anthocyanin
Brilliant blue
Canthaxanthine
Carbon black
Citrus red #2
Cochineal
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Erythrosine
Fast green
Indigotine
Iron oxide
Orchil
Ponceau
Saunderswood
Sunset yellow
Tartrazine
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Sulphites
The following sulphites, singly or in combination may
be listed as “sulphiting agents” or “sulphites”:
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Potassium bisulphite
Potassium metabisulphite
Sodium bisulphite
Sodium metabisulphite
Sodium sulphite
Sodium dithionite
Sulphurous acid
Sulphur dioxide
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Monosodium glutamate (MSG)
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There are no regulations requiring this flavour
to be identified specifically
Manufacturers can list the additive by the
source, e.g.
Hydrolysed vegetable protein (HVP)
 Hydrolysed plant protein (HPP)
 Hydrolysed soy protein (HSP)
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If the hydrolysate is derived from a priority
allergen it should appear on the label
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HSP should identify “soy” as an allergen
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Chicken noodle soup mix
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Grissol
Melba Toast
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Chicken noodle soup mix
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Food Services
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Role of the dietitian is to ensure all meals
provided to identified food allergic individuals
are free from their offending allergens
Concern when patients designate food
aversions as “allergies”
Request confirmation of allergy from medical
practitioner if necessary
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Identification of Allergens
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Computer coding, example:
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List of ingredients with allergens identified in side-by-side
columns
List priority allergens
List allergens of common concern, e.g.
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Corn
Rice
Individual meats, fruits, vegetables
List additives of concern, e.g.
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Sulphites
MSG
Tartrazine
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What about secondary ingredients?
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If not listed on label, need not include as
allergens, e.g.
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Sulphite in fruit purée
If label identifies a priority allergen in a
precautionary statement (as “may contain”) list
as allergen present
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Food Preparation
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Is it practical to designate areas as allergenfree?
Which allergens should be excluded?
 All priority allergens?
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Are all prepackaged and preprepared foods
entering the facility adequately labelled?
How can meals on an assembly line be
considered “allergen-free”
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Precautionary Statements
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Dietitian can only ensure that an allergic
patient’s meals are free from known sources of
the allergen
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Contamination from foods prepared in the same
area cannot be avoided
“Prepared in a facility that also processes
foods containing [X]”
New labelling rules suggest this should read,
“may contain [X]”
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PREVENTION OF
ALLERGY
Recent Changes in Direction
Prevention of Allergy:
Historical Perspective
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Measures of prevention were all designed to avoid
sensitization to allergens during what were
considered the most vulnerable periods:
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This meant reduction in exposure to highly allergenic
foods:
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Intra-uterine life
From birth to 2-3 years
Mother’s diet during pregnancy and lactation
Delay in introduction of highly allergenic foods during
weaning
In spite of these stringent measures to prevent allergy,
incidence of all types of allergies have increased
significantly
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Change in Direction During the Past
Five Years
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Understanding of the importance of immunological
sensitization and tolerance
Recognition that tolerance not sensitization is the
critical step in allergy prevention
Finding that exposure to the allergenic food at an
optimum stage is probably a critical step in allergy
prevention
Recognition that tolerance can be induced after
allergy has been established – leading to important
measures for allergy management
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Allergy is a Response of the Immune System
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Our immune systems are designed to protect
the body from invasion by foreign materials
All foods contain proteins – derived from
plants and animals – all of which are foreign to
the human body
In order for food to be absorbed, metabolized,
and utilized by the body, the immune system
needs to be “educated” that the foreign
material is safe
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Herz 2008
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Oral Tolerance
of the T cells to not respond
to that food protein when it enters via the
oral route – called oral tolerance
 Contrasts with the active immune
responses needed to protect the gut
against continual bombardment by
invading pathogens and their products
(toxins, etc)
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“Education”
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Prevention of Food Allergy in Clinical
Practice
Significant change in directives within the past 5
years:
 Previously:
Avoidance of allergen to prevent
sensitization (allergen-specific IgE)
 Current:
Active stimulation of the immature
immune system to induce tolerance of the
antigens in food
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Rautava et al 2005
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Factors Predictive of Allergy:
High and Low risk Groups
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Many factors investigated as possible
predictive markers for allergy
Only significant variable in studies:
Family history of allergy (all types)
High risk for allergy:
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One first degree relative with diagnosed
allergy (IgE-mediated) of any type
First-degree relative: parent or sibling
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When does Tolerance of Foods Begin?
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Food proteins demonstrated to cross the
placenta and can be detected in amniotic
fluid
Exposure to small quantities of food
antigens from mother’s diet thought to
tolerize the fetus, by means of IgG1 and
IgG3, within a “protected environment”
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Diet During Pregnancy
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Current directive: the atopic mother should strictly
avoid her own allergens and replace the foods with
nutritionally equivalent substitutes
There are no indications for mother to avoid other
foods during pregnancy
A nutritionally complete, well-balanced diet is
essential
Authorities recommend avoidance of excessive intake
of highly allergenic foods such as peanuts and nuts to
prevent “allergen overload”, but there is no scientific
data to support this
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Kramer et al 2006
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Sicherer et al 2010
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Implications of Research Data
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Exclusive breast-feeding with exclusion of
mother’s and baby’s allergens will reduce signs of
allergy in the first 1-2 years; specifically:
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Reduction or prevention of early food allergy by
breast-feeding does not seem to have long-term
effects on the development of:
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Cow’s milk allergy
Eczema (atopic dermatitis)
Asthma
Allergic rhinitis (hay fever)
Exclusive breast-feeding for 4-6 months is
strongly encouraged
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Summary of 2008 AAP Guidelines for Allergy
Management [Greer et al 2008]
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There is no convincing evidence that
women who avoid highly allergenic
foods, or other foods during
pregnancy and breast-feeding lower
their child’s risk of allergies
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Greer et al 2008
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Value of Breast-feeding
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For high-risk for allergy infants (one
first-degree relative with established
allergy), exclusive breast-feeding for at
least 4 months prevents or delays the
occurrence of:
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Atopic dermatitis (eczema)
Cow’s milk allergy (CMA)
Wheezing
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Sicherer and Burks 2008
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Preventive Effect of Breast-feeding:
KOALA Study
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Longer duration of breastfeeding is associated with
lower risk for eczema in non-atopic mothers
Slightly lower risk for mothers with allergy but no
asthma
Longer duration of breastfeeding reduced risk for
wheezing in infants: possibly due to reduction in
respiratory infections
There is a lack of evidence that exclusive or
prolonged breast-feeding has any positive effect on
the development of asthma in older children
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Snijders et al 2007 KOALA study
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Summary of 2008 AAP Guidelines
continued
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In infants at high risk for allergy who are not
exclusively breast-fed for 4-6 months there is
modest evidence that the onset of allergy,
especially eczema, may be delayed or
prevented by the use of hydrolyzed formulas
There is no good evidence that soy-based
infant formulas have any preventive effect on
the development of allergy
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Preventive Effect of Hydrolyzed Infant
Formulae
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No evidence of any reduction in allergy with
hydrolyzed formula compared to breastfeeding
Limited evidence that prolonged feeding with
hydrolyzed formula compared to cow’s milk reduces
incidence of CMA and eczema
No evidence that hydrolyzed formulas have any effect
on the development of rhinitis and asthma later
Extensively hydrolyzed cow’s milk (Ehf) formulas
better than partially hydrolyzed whey (Phf) in
prevention
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Osborn and Sinn 2009 Cochrane Review
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Von Berg et al GINI Study 2009
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Infant Formulae for the Allergic Baby
Current Recommendations
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Cow’s milk based formula if there are no signs
of milk allergy
Partially hydrolysed (phf) whey-based formula
if there are no signs of milk allergy in high risk
for allergy group
Extensively hydrolysed (ehf) casein based
formula if milk allergy is proven
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Greer et al AAP 2008
Von Berg et al 2007
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Recommendations for Introduction of Solids
to High Risk for Allergy Infants
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Little evidence that delaying the introduction of
complementary foods beyond 4-6 months of age
prevents allergy
Introduction of solid foods should be individualized
Foods should be introduced one at a time in small
amounts
Mixed foods containing various potential food
allergens should not be given unless tolerance to each
ingredient has been assessed
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Greer et al AAP 2008
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Thygaran and Burks 2008
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Introduction of Solid Foods in
Relationship to Celiac Disease
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Results suggest that in high risk for celiac disease
infants introduction of gluten-containing grains
before 3 months or after 7 months increases
incidences of development of CD1
Introduction of gluten while breast-feeding offers
protection or delays onset of celiac disease in at-risk
infants2
Recommendations:
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Introduce gluten grains in small amounts between 4 and 6
months while infant is breastfed
Continue breast-feeding for a further 2-3 months
Similar results for wheat allergy3
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1Norris et al 2005
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2Guandalini 2007
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3Poole et al 2006
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Introduction of Peanuts
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Directives from pediatric societies (1998 - 2007)
recommended avoidance of peanuts by mothers
during pregnancy and lactation, and delaying
introduction of peanuts until after 2 or even 3 years of
age
Research indicates that incidence of peanut allergy in
children rose dramatically in the years following
release of these directives
Recent research suggests:
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Avoidance of peanuts reduced development of tolerance
Early exposure leads to reduced incidence of peanut allergy
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Hourihane et al 2007
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Du Toit et al 2008
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Introduction of Fish
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Historically, fish consumption during infancy was
considered to be a risk factor for allergy
Recent research indicates otherwise:
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Regular fish consumption during the first year of life
associated with a reduced risk for allergic disease by age 4
years (n=4089)1
Babies of mothers who frequently consumed fish (2-3
times per week or more) during pregnancy had one third
less food sensitivities than those whose mothers did not
consume fish during pregnancy2
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1Kull et al 2006
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2Calvani et al 2006
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The Natural History of Food Allergy
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Food allergy most often begins in the first 1 to
2 years of life
Child is sensitized to the food protein by the
immune system developing allergen-specific
IgE to that protein
Sensitization does not necessarily mean that
the child will develop symptoms when that
food is eaten
Over time most food allergy is lost
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Wood 2003
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Prognosis
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Most children outgrow early food allergy
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John’s Hopkins Children’s Center USA
 Milk allergy outgrown:
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Egg allergy outgrown:
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20% by 4 years
42% by 8 years
79% by 16 years
4% by 4 years
37% by 10 years
68% by 16 years
Allergy to some foods more often than others persists into
adulthood:
 Peanut
 Tree nuts
 Seeds
 Shellfish
 Fish
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Skripak et al 2007
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Induction of Oral Tolerance
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Tolerance to a specific food can be induced by
oral administration of the offending food by
process of “low dose continuous exposure”
Designated (SOTI: specific oral tolerance
induction)
Starting with very low dosages
Gradually increasing daily dosage up to the
equivalent of the usual daily intake
Followed by daily maintenance dose
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Niggemann et al 2006
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Calvani et al 2010
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Oral Tolerance Induction to
Milk, Egg, and Peanut
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36% of children with IgE-mediated allergy to cow’s
milk and hen’s egg developed permanent tolerance of
the foods after a median 21 months specific oral
tolerance induction (SOTI)1
4 peanut-allergic children underwent SOTI:
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Daily doses of peanut flour starting at 5 mg peanut protein
2-weekly dosage increase up to 800 mg protein
All subjects tolerated at least 10 whole peanuts (2.38 g
protein) on post-intervention challenge2
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1Staden et al 2007
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2Clark et al 2009
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Progression of Peanut Allergy
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Peanut allergy, like many early food allergies, can be
outgrown
In 2001 pediatric allergists in the U.S. reported that
about 21.5 per cent of children will eventually
outgrow their peanut allergy1
Those with a mild peanut allergy, as determined by
the level of peanut-specific IgE in their blood, have a
50% chance of outgrowing the allergy2
Only about 9% of patients are reported to outgrow
their allergy to tree nuts3
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1Skolnick et al 2001
2Fleischer et al 2003
3Fleischer et al 2005
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Maintaining Tolerance of Peanut
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When there is no longer any evidence of symptoms
developing after a child has consumed peanuts, it is
preferable for that child to eat peanuts regularly,
rather than avoid them, in order to maintain tolerance
to the peanut
Children who outgrow peanut allergy are at risk for
recurrence, but the risk has been shown to be
significantly higher for those who continue to avoid
peanuts after resolution of their symptoms
_________________
Fleischer et al 2004
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