Originally published in The Ottawa Citizen December 2, 2003
Original Title: Wasting away on a full stomach

Part I – Don’t wait to deal with heartburn pain

Richard (not his real name) was a happy one year-old infant. After his first birthday he developed bloating and diarrhea and lost weight. His growth slowed. This condition persisted for months.

His mother, suspicious about a food-related condition, maintained a food diary. She noted that bread and cereal seemed to make him worse. A preliminary diagnosis of celiac disease (sprue or gluten-sensitive enteropathy) was made and was subsequently confirmed by a biopsy of the small intestine.

Reports of celiac disease began in the late 19th century. However, it was not until the mid 20th century when the removal of wheat and wheat products from the diet led to dramatic improvements. Celiac disease occurs when the protein gluten, found in wheat, stimulates a complex series of immune system events. These events produce an antibody that attacks the small intestine (an autoimmune reaction) compromising its ability to absorb nutrients. Certain autoimmune diseases like lupus and rheumatoid arthritis among others are associated with celiac disease.

Celiac disease affects one in 250 people. Some do not manifest any gastrointestinal symptoms but tend to have other problems like chronic fatigue, chronic diarrhea, unexplained weight loss, short stature, epilepsy and infertility.

If someone has a first-degree family member with celiac, his/her risk of developing celiac increases by ten to twenty per cent. Seven per cent of type 1 diabetics will also have celiac disease.

Celiac disease usually begins in infancy. Infants typically develop failure to thrive, bloating and abdominal distention, diarrhea, developmental delay and occasional severe malnutrition. Left undiagnosed, the condition can become a medical emergency.

The effects of celiac disease tend to be less severe in later childhood. Indeed, older children may end up with brittle teeth due to enamel breakdown or remain short for their age as the only signs of the disease.

Women comprise 75 per cent of new adult celiac disease cases. Common digestive system symptoms include diarrhea, constipation, bloating, gas and burping. They may experience chronic fatigue, fibromyalgia-like symptoms, mouth ulcers, stomach ache, acid reflux and heartburn and bone pain.

About ten per cent of adults will develop an intensely itchy red rash with tiny bubbles or vesicles that look like herpes on the buttocks, knees, back and elbows. This rash, dermatitis herpetiformis, can be misdiagnosed as a form of psoriasis or eczema.

Iron is absorbed by the small intestine. Iron deficiency anemia is commonly found in about half of the new cases of celiac disease because of the damage to the small intestine. This damage can also cause intestinal bleeding in about 50 per cent of patients too. Vitamin B12 and folic acid deficiency can also occur.

The diagnosis of celiac disease can be made on the basis of a blood test. This test looks for the antibodies that attack the intestine. The most accurate test is the IgA antiendomysial antibody test.

Many of the complications of the disease relate to the lack of nutrient absorption in the small intestine. The lack of calcium and vitamin D absorption can lead to a reduction in bone calcium ranging from mild loss (osteopenia) to severe loss (osteoporosis).

Nerve and brain damage may occur because the celiac-created antibodies (autoantibodies) attack the arteries of the brain. Calcium may deposit in the brain tissue potentially leading to epilepsy. Other nerve damage includes an inability to maintain posture and peripheral neuropathy (reduced sensation in the lower legs and feet).

Untreated patients are at risk for two forms of cancer, a leukemia called T-cell lymphoma and bowel adenocarcinoma. Proper life-long treatment and control of celiac disease will reduce this risk to that of the general population.

It is imperative to have a dietician design an appropriate diet. Completely removing gluten and its related proteins, found in wheat, barley and rye, is the only means to control the disease. The disease’s complications can be prevented or reversed with the addition of iron, folic acid, calcium and vitamin D supplements to the gluten-free diet.

Rice, corn, maize, flax, quinoa, tapioca, potato, amaranth, and other grain substitutes, such as nuts and beans, are safe. Pure oats are considered safe in small quantities but commercial oat products may contain wheat and other “impurities”

Fruits, vegetables, meats, and most dairy products are safe to eat. Specialty stores sell gluten-free breads, cereals, cookies and chips.

Consult your family doctor if you have chronic fatigue and diarrhea, unexplained weight loss, irritable bowel syndrome, iron deficiency anemia, epilepsy, short stature, infertility, a medical history of thyroid disease or type I diabetes or a family history of Celiac disease. This is another of the “silent” diseases out there that can be effectively treated.

Richard has followed a gluten-free diet for ten years. He remains in good health and lives a normal kid life.

For more information:
Canadian Celiac Association: http://www.celiac.ca/
Celiac Canada: http://www.penny.ca/Celiac-canada.htm

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Originally published in The Ottawa Citizen May 20, 2003
Original Title: How to Produce a Natural Allergy

Proteins in some plants and products so closely resemble pollen antigens, they can confuse the immune system, trigger allergic reactions.

It’s spring and that means allergies are again exacting their seasonal vengeance.

Many people don’t know it, but pollen allergies can increase the risk of severe allergic reactions to other plants, foods and herbal or naturopathic remedies.

The proteins (antigens) within these plants and products resemble pollen antigens: the proteins that trigger an allergic reaction. The similarity can confuse the immune system, causing an allergic response.

This cross-reactivity of antigens in an unsuspecting person is an important concept in allergy and immunology. For example, a person allergic to birch pollen may have an allergy to apples.

• Fifty to 90 per cent of people allergic to birch pollen can react to nuts, fruits such as kiwi, apples, pears and plums and vegetables like potatoes, tomatoes, celery and carrots.
• Grass pollen has a cross-reaction relationship with carrots, potatoes, celery, tomatoes, buckwheat, melons, oranges and Swiss chard.
• Ragweed sufferers should be careful about zucchini, cucumbers, bananas, melons (cantaloupe, honeydew and watermelon), apples, chamomile tea, honey, nuts and sunflower seeds.
• Some foods will cause oral allergy syndrome in people afflicted with airborne allergies. The symptoms include a raw, itchy rash around the mouth. Some people develop a full-blown allergic reaction.

In the spring 2003 edition of the Allergy and Asthma News, Ottawa allergist Dr. Antony J. Ham Pong writes about allergies to herbal products: Hay fever (ragweed allergy) sufferers are at risk of severe allergic reactions or anaphylaxis if they use certain herbal and naturopathic remedies.

• Chamomile, feverfew and echinacea belong to the compositae plant family, which includes ragweed, goldenrod, chrysanthemum, sunflower, sagebrush, mugwort, marigolds and daisies.
• Chamomile, used as a digestive aid, to treat menstrual cramps, as an enema preparation and as a topical antibiotic, increases the risk of anaphylaxis and death.
• Echinacea, considered by some to be an immune booster and to treat allergies and colds, can itself cause anaphylaxis, allergic skin rashes and asthma attacks. Feverfew, used to treat migraine headaches, produces similar reactions.
• Bee honey, a food tonic, can contain pollen grains and antigens leading to hives, an itchy mouth and throat and anaphylaxis.
• Royal jelly — the secretion from worker honeybees — may contain compositae pollens and may cross-react with dust mites.

Several products interact with standard allergy medications: the antihistamines and decongestants. They can augment the sedating effects of antihistamines found in cough and cold remedies like dephenhydramine (Benadryl), hydroxyzine (Atarax) and chlorpheniramine (Chlor-Tripolon).
Kava’s sedating effects are used to treat anxiety, stress and insomnia. Unfortunately, it can lead to excessive sedation and poor co-ordination when combined with certain antihistamines. Health Canada does not recommend its use because it can cause severe liver toxicity.
Valerian can cause similar side effects as Kava.

• Ephedra is used to treat asthma, colds, hay fever, obesity and for bodybuilding. Using decongestants like pseudoephedrine (Sudafed) in combination with ephedra can cause dizziness, headaches, irregular heart rhythms, increased blood pressure, seizures, tremors, strokes and death. Health Canada also issued a warning about ephedra.
• Cross-reactivity may explain why workers such a nurses who use latex gloves often develop an allergy to the gloves. The raw material for latex comes from trees. Latex can cross-react with avocado, kiwi, banana, peaches, chestnuts and melons. Changes in latex production may leave more antigens within the final product, increasing the chance of an allergic response.

According to allergy specialist Dr. Yezdi Patel, people who eat shrimp, celery, carrot or dillweed prior to aerobic exercise may experience an allergic reaction. The mechanism that causes the reaction remains unknown.

Future research may help find better ways to reduce the risk and relieve allergy symptoms. Consult your doctor or pharmacist about potential herbal/drug interactions and allergy risks.

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Originally published in The Ottawa Citizen April 15, 2003
Original Title: When to use an EpiPen

A recent pharmacist’s study presented to the Canadian Society of Allergy and Clinical Immunology indicates 63 per cent do not know how to use an EpiPen and 62.5 per cent cannot recognize the signs and symptoms of a severe allergic reaction (anaphylaxis).

Medications (penicillin, nonsteroidal anti-inflammatory drugs and aspirin, chemotherapy agents and angiotensin-converting enzyme inhibitors (ACEs)), bee and wasp stings, milk, seafood, nuts, blood transfusions, exercise and other chemical agents can trigger anaphylaxis.

The most common food allergies children develop in their first three years of life are to cow’s milk, peanuts, soy, eggs, shellfish and wheat. Peanuts, nuts and fish tend to be lifelong.

Two cell types, mast cells and basophils, are responsible for the allergic response. It is unknown why the response varies between people. Some develop a few hives or itchy skin whereas others develop a life threatening condition when the mast cells and basophils release abnormal quantities of chemical substances including histamine.

The blood vessels will dilate and leak fluid into the surrounding tissue causing swelling (angioedema) of the skin. Severe fluid loss leads to a collapse of the circulatory system.

The smooth muscle rings that encircle the airways (bronchi) will constrict. The airways themselves will produce copious amounts of mucous. The combination of these two effects plugs the airway making it impossible to breathe. Fluid can accumulate within the lungs leading to heart failure.

These and other reactions usually develop within five to 60 minutes after exposure. There can be a delay of one to eight hours before anaphylaxis occurs so vigilance is a priority.

The symptoms include:

• Itching, flushing, hives and swelling of the skin and sweating
• Itching, tearing and swelling of the tissues around the eyes
• Nasal congestion, runny nose, sneezing and a metallic taste in the mouth
• Difficulty breathing, wheezing, increased airway secretions and mucous production, swelling of the upper throat, blueness of the skin (cyanosis), hoarse voice, sounds of laboured breathing and a choking sensation
• Very rapid or very slow heart beat, an irregular heart beat, low blood pressure and cardiac arrest
• Nausea, vomiting, abdominal cramps, bloating and diarrhea
• Dizziness, weakness, fainting, a fear of impending doom and seizures
• Ninety per cent of people with allergic reactions have hives and skin swelling after feeling itchy, flushed and fearing impending doom.

Breathing difficulties occur in 50 per cent of these people especially those with asthma. Gastrointestinal symptoms and extremely low blood pressure (anaphylactic shock) occurs in 30 per cent.

Five to 20 per cent of people may have an initial allergic reaction that resolves but recurs one to eight hours later. Be on guard for this phenomenon. This happens when a person develops symptoms 30 minutes after exposure and in those orally ingesting the substance.

People at greatest risk of anaphylaxis have a history of asthma, eczema, allergic rhinitis (nasal allergies) and hives. Injection and intravenous administration of the allergen is likely to be more severe than if swallowed. Inhalation can provoke a response.

In the event of anaphylaxis, epinephrine will give you 15 to 20 minutes to get to an emergency room. Epinephrine counters the allergic response by constricting the blood vessels, relaxing the smooth muscle of the airways to improve breathing, stimulating the heartbeat, and reversing hives and swelling about the face and lips. Antihistamines will not reverse anaphylaxis fast enough to make a difference.

Emergency epinephrine provided in the EpiPen format is a spring-loaded syringe containing a pre-measured dose of epinephrine. A junior format is available for children weighing under 15 kilograms or 33 pounds.

To use the EpiPen follow these directions.

1. Slide the protective plastic sleeve off the unit
2. Remove the gray safety cap. Do not touch the black plastic tip.
3. With your dominant hand hold the EpiPen and position the black tip against the fleshy outer portion of the thigh. Keep all fingers clear of the black tip.
4. Push the pen against the thigh for five to ten seconds. Massage the area after the injection. Pain is minimal
5. A needle sticking out the end of the pen after you are done indicates proper delivery of the medication into the skin
6. Call 911 or seek emergency medical assistance.

You can inject through thin clothing if need be. View an animated version of EpiPen technique at www.epipen.com. The Calgary Allergy Network is another source of information (http://www.calgaryallergy.ca/Articles/epipen.html).

Your pharmacist can demonstrate how to use the EpiPen. An Ottawa company, Allergy Essentials (www.allergy-essentials.com) sells EpiPen trainers (fully functional without the needle for $6.50). Please take the few minutes to learn to save the time of your life.

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Originally published in The Ottawa Citizen April 1, 2003
Original Title: Mighty Mites!

Allergies affect millions of people in North America. Although medications help to control asthma, allergic rhinitis and eczema, control of our local living environment is essential. Prevention can reduce or eliminate the need for medications.

Our homes are hosts to millions of creatures and organisms that produce waste material. This material (allergens) is the source of allergy-based misery. Without proper identification of these allergens, it is difficult to provide long-lasting relief.

Over years of exposure to allergens, the immune system tends to overreact and produce an allergic response. This process is called sensitization. Exposure to various household allergens can lead to dry skin rashes or eczema, asthma, stuffy nose (rhinitis) and watery eyes (conjunctivitis). Allergy testing helps determine those allergens responsible for these conditions.

Dust mites infest our homes. These critters, related to the spider family, are 0.3 millimeters in size and love to eat our dead flaking skin. They live in dusty places with an ambient temperature of 21°C and relative humidity of 70 per cent. The mite’s fecal pellets cause the allergy. These relatively large pellets (from a microscopic standpoint) only remain airborne for several minutes once disturbed.

The areas of your home prone to these guys are carpets, pillows, mattresses, drapes, stuffed animals, clothing and upholstered furniture. Since these items are frequently used, the pellets will fly.

A pet’s skin, saliva, urine and feces provide a rich allergen source. Cat dander is the worst offender. It can remain airborne for some time, enough to spread throughout the house. Dander levels can remain in the house an average of 20 weeks after the cat has moved on. Further, it is impossible to remove cat dander from bedding, mattresses, carpets and furniture.

Cockroach allergens, found in household dust, have a strong link to asthma according to some studies. Roaches tend to congregate in dark areas of the kitchen feeding off crumbs and scraps of food falling into the nooks and crannies.

Indoor and outdoor fungi or moulds, Cladosporium, Penicillium, Aspergillus, Aternaria and Ganoderma produce spores that can cause asthma. The Weather Network (http://www.theweathernetwork.com/features/pollen/) reports the summertime spore counts.

Environmental control measures are essential to prevent or minimize allergic reactions. Indeed, identification and subsequent eradication of the offending allergens early in a child’s life can reduce the risk of asthma. Medications and allergy shots should be part of the treatment if necessary and not the sole therapy.

If you smoke in the house, stop. Smoke permeates throughout the house even if you lock yourself in a room. Children are most susceptible to the affects of second hand smoke increasing their risk of lung disease, asthma and ear infections. Smoking during pregnancy increases a child’s risk of asthma twofold and can cause a three to five per cent reduction in lung function.

Dust mite control will lead to a cleaner less irritating environment:

• Pillows and mattresses should have a vinyl or semipermaeable cover. This can reduce the population 100 to 1000 fold
• Wash all sheets, pillowcases and comforters every one to two weeks in hot water (54°C or 130°F).
• Dry cleaning and tumble drying at 54°C will kill the mites
• Remove bedroom carpeting and any that overlies concrete. Regular vacuuming does not remove the dust mites.
• Wet mopping all vinyl and hardwood floors weekly can remove 90 per cent of the allergen.
• Reduce indoor humidity to 50 per cent or less.
• Ensure that your child’ stuffed toys are washable. Throw out those that are not.
• Chemical agents that kill mites are not effective.
• Since pet allergy sufferers rarely remove their pet from the home, the next best choice is to keep them out of the bedroom and off the carpets and upholstered furniture.

Avoidance of pets during infancy is not a recommendation. There is some evidence to suggest exposure at this age can reduce the risk of asthma and allergies.

Any way you can kill cockroaches is acceptable. Share your method with others. Clean up any food spills and keep the kitchen spotless.

Indoor moulds need moisture to grow. Check for any water leaks or damp areas. Use a dehumidifier in the basement to reduce the humidity level to less than 50 per cent.

These measures are relatively easy and economical to institute. Most people suffering from asthma should benefit from allergy testing. These straightforward steps can reduce exposure to substances that allow you to smell the roses – provided you are not allergic.

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