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Contents A. Case study B. More information C. Editors' comments D. References E. CEU questions

Index

A. Case study
A 16-year-old girl was referred to a dietitian for assistance with weight gain; her BMI was 18. After a clinical and dietary history, it was determined that she had been following a severely restricted diet based on the results of an IgG test. The IgG test was performed to find the cause of her ongoing sinus headaches. (Note that sinusitis is often an encompassing term for a range of sinus problems such as sinus headaches [negative-air pressure from sinus entrance congestion and closure, which often accompany allergic rhinitis], mucus in the sinus resulting in positive pressure, and infection in the sinuses.)

The results of the IgG test showed a “food intolerance” to wheat, gluten, cow’s milk, egg and cashew nuts. Being a teenager, she also was a picky eater. She was a lacto-ovo vegetarian, and the foods that she had most enjoyed eating were those that she now had to avoid. Her diet was therefore very limited. She had lost 7 kg in the 2 months of the restrictive diet. Her sinusitis had not improved significantly.

In further investigations, other possible causes were excluded, and it was determined that the weight loss was most likely linked to the restrictive diet.

THOUGHT PROCESS:
Are the identified foods truly the cause of the sinusitis?
Apart from the fact that IgG testing is not a scientifically confirmed diagnostic test for allergy or intolerance, so that the results cannot be trusted, the girl’s symptoms had not improved after excluding these foods. The foods are therefore most likely not the cause for her sinusitis.

Can all the foods be reintegrated into the diet?
As her symptoms have not changed significantly after the exclusion of the foods, and she had apparently been eating these foods without adverse effects before, the foods can safely be put back into the diet.

Can the sinusitis be caused by anything other than food(s)?
Yes, it can be caused by inhalant allergens as well. The most prevalent and significannt causes for allergic rhinitis and/or sinusitis are aeroallergens such as pollens, mites, and mould.

How does one determine the true cause of the sinusitis?
a. Clinical history and physical examination
b. Serum-IgE testing
c. Skin prick testing
d. Food-symptom diary
e. Elimination diet and challenge

DISCUSSION:
a. Through these it may appear that the cause is most likely to be of inhalant or food origin; important considerations would be the frequency and dates of the sinusitis.
b and c. One of these tests may be appropriate in determining the cause. Which allergen to test for will be based on the results of a.
d and e. One of these may be appropriate, or even diagnostically required, if food is suspected as a cause.

The patient was referred to a an ear, nose and throat specialist for a thorough clinical history and physical examination. It was determined that she had a house dust mite allergy, and that there was no evidence of food sensitivities. The dietitian advised her on how best to return to her usual diet.

TIP for Allergy Advisor users: There is an article in Allergy Advisor that can be used for a quick reference: "Unorthodox methods of diagnosis and treatment". It can be found under Assessement, Assessment guides/checklists, Assessment guides.

B. More information:
Along with the recent and ongoing increase of allergic diseases in the general populations of western countries, there is a risk of over-diagnosis. Unorthodox allergy approaches often attribute a wide range of conditions, e.g., headaches, migraine, irritable bowel syndrome, muscle tension, pain, addiction, premenstrual syndrome, fatigue or depression, to immune basis,^1,2 and therefore attributed to an “allergy”. Some proponents of these approaches argue that orthodox medicine does not recognise the delayed reactions purportedly measured by unconventional tests, when in fact delayed reactions are well accepted by all allergy clinicians and organisations.

There is a growing number of unconventional, unproven, and inappropriate procedures that are claimed to diagnose and treat allergic disease. Some of these "tests" are legitimate in themselves but misused in the context of allergy. Others have no basis in the pathophysiology of allergic disease.³

According to some claims, allergy and other diseases are a) caused by the disturbance of vital life force or energy ("Qi", “yin-yang,” etc.), or b) secondary to noxious external triggers such as environmental toxins, chemicals, food allergens / additives or chronic infection with organisms like Candida albicans. It is claimed that the body can generally cure itself if given the opportunity to correct these imbalances on the one hand, or to avoid/eliminate environmental toxins, allergens or occult infection on the other. These philosophies use terminology loosely, blur and confuse scientific evidence, and blend concepts of immunology, neurology and spirituality to explain the nature and causes of disease.¹

The following is a summary of the most common unorthodox techniques and practices used to diagnose and treat allergy and intolerance.

Cytotoxic testing (Bryans' test or ALCAT)
Use: Diagnosis of food sensitivity or allergy.
Method: A suspension of patient leukocytes is incubated with dried food extracts on a microscope slide. Alterations in the appearance and movement of cells are interpreted as a sensitivity or "allergy" to that food. The ALCAT test is a variation whereby a mixture of blood and food extracts is analysed.^1,3,4
Evidence: The test "results" invariably are reported as indicating multiple food allergies, but investigation of these reports shows clearly that there is no correlation with clinical food allergy or intolerance.^3,4 Studies have shown results to be poorly reproducible when samples a few days apart have been submitted to the same laboratory for testing.^1,4 Not a single allergy society in the world supports this test for routine diagnostic purposes.

Food specific IgG, IgG4
Use: Diagnosis of food sensitivity/allergy.
Method: IgG (not IgE) antibodies to food are measured using standard laboratory techniques.
Evidence: Low levels of IgG antibodies to food are commonly detectable in healthy adults and children, independent of the presence of absence of food-related symptoms. There is no credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, nor that IgG antibodies cause symptoms. The exception is that gliadin IgG antibodies are sometimes useful in monitoring adherence to a gluten-free diet in patients with confirmed Celiac Disease.^1,3,4,5 Not a single allergy society in the world supports this test for routine diagnostic purposes.

Hair analysis
Use: Diagnosis of food sensitivity/allergy and other non-specific symptoms
Method: Trace elements are measured from samples of hair, and nutritional deficiencies or excesses are connected to the patient's symptoms.
Evidence: While hair analysis is employed for toxicological and forensic use, there is no evidence that vitamin or mineral analysis from hair samples is useful for diagnosing disease. Blinded studies have shown variable and non-reproducible results from the same samples sent to the same and different laboratories.^1,5

Iridology
Use: Diagnosis of various disorders.
Method: Iridology is based on the concept that each part of the body is represented by a corresponding part of the iris. A person's state of current and past health is diagnosed from the color, texture, and location of pigment flecks in the eye. Imbalances are treated with dietary supplements or herbal medicines.
Evidence: Iridology shares a similar conceptual framework to those of reflexology and acupuncture. Studies have shown that iridologists are unable to distinguish patients with disease from healthy subjects, and that they give varying diagnoses when examining iris photographs from the same individuals, taken a few minutes apart. Furthermore, iris patterns remain constant throughout life, enabling them to be used for reliable personal ('biometric') identification. The theoretical basis of iridology is therefore questionable.¹

Kinesiology (or Applied Kinesiology)
Use: Diagnosis of food sensitivity/allergy.
Method: This method is based on the concept that exposure to exogenous toxins or allergens will result in a reduction in muscle strength. In some cases a glass vial containing a specific allergen is placed on or near the body of the patient; in other cases, the patient is asked to hold the vial. During allergen "exposure," muscle strength is tested. Strength is measured before and after exposure to food. A positive test is indicated by observed muscle weakening. Children are assessed by testing the parent's strength first and then through holding the child's hand. The first test result is subtracted from the second to give the final result.^1,3,4
Evidence: This technique has no physiological basis, and interpretation is innately subjective. Formal studies have shown poor reproducibility between duplicate tests, and poor correlation with the results of conventional allergy testing.^1,3,4,6 It is suggested that the use of Kinesiology as a diagnostic tool is not more useful than random guessing.^5,7

Oral provocation and neutralisation
Use: Diagnosis and treatment of sensitivity to foods, inhaled allergens and environmental chemicals.
Method: Drops of dilute extracts are administered under the tongue, intradermally or subcutaneously. The patient is observed for 10 minutes, and any symptoms are recorded. If the patient remains symptom-free, then increasing doses of extract are given until symptoms do occur. Once these symptoms occur, the patient is immediately given injections of weaker dilutions of the same extract until symptoms are resolved. This amount of extract is considered the "neutralising dose" and is used for future treatment. As “treatment”, the patient is instructed to use this "neutralising dose" before exposure to the offending environmental trigger.
Evidence: The technique appears vague and imprecise; there appears to be no established protocol for performing or interpreting this test. The majority of the studies were not able to demonstrate any benefit from neutralising solution compared with placebo.^1,3

Pulse testing
Use: Diagnosis of food sensitivity/allergy.
Method: This test is based on the rationale that allergic reactions are mediated by nerve impulses transmitted by the sympathetic nervous system, and that allergen exposure will result in a temporary increase in heart rate. An increase in the pulse rate of greater than l0 beats per minute after eating a food has been claimed to indicate allergy to that food. However, the procedure has never been standardised. The “auricular cardiac reflex test” is a variation in which food sensitivity is assessed by changes in pulse waveform.^1,3,4
Evidence: This technique is subjective by its nature, and there is no evidence that results are useful for diagnosing any disorder, including allergies.^1,4

Radionics (psionic medicine, dowsing)
Use: Diagnosis and treatment of food sensitivity/allergy, infections and various other medical conditions.
Method: Radionics is based on the concept that all life forms are submerged in the electro-magnetic energy field of the earth, and that disease will be indicated by changes or "imbalances" in an individual's electromagnetic field that bring it outside the normal electromagnetic spectrum. Practitioners of radionics claim to be able to detect subtle changes in energies and vibrations arising from internal organs affected by disease, by using a pendulum-like device to amplify these changes. Sometimes more sophisticated instruments are used to "tune in" to disease-specific energies. Sometimes the operator is with the patient, and sometimes the practitioner "connects" with the patient at a distance using an object such as a lock of hair, blood sample or photograph. By focusing their own thoughts and energies, practitioners claim to treat disease by restoring normal energy balance.
Evidence: This technique combines concepts of kinesiology, reflexology, vega testing, "ESP" and the paranormal. This technique has not undergone formal study, and there is no published data indicating that it is effective for the diagnosis or treatment of any disorder.¹

Tests for 'dysbiosis'
Use: Diagnosis of food sensitivity/allergy and of the aetiology of non-specific symptoms
Method: Some laboratories offer pathology tests, including stool bacterial testing, chemical analysis, urine metabolite profiles, intestinal permeability assays, trace metal analysis, Candida antibody/cellular proliferation assays, and blood/urine fatty acid and amino acid profiles, all for assessment of "dysbiosis". The concept of 'dysbiosis' holds that there is a balance of 'good' versus 'bad' bacteria in the bowel of each person. Imbalances result in disease, which can be assessed by various metabolic and bacteriological measurements. Such tests are often used by unorthodox practitioners as a rationale to prescribe a) megadose nutritional supplementation; b) 'probiotic' and/or antibiotic therapy; or c) dietary modifications. These treatments are promoted as a means of restoring a 'healthy' balance of bowel flora.
Evidence: There is no sound scientific evidence to support 'dysbiosis’ as a cause of allergic diseases or related clinical conditions.¹ (This evaluation does not cover the use of probiotics in the prevention and treatment of allergic conditions.)

Vega testing (or BEST test) (electrodermal testing)
Use: Diagnosis of a range of diseases, including allergy, sinusitis, chronic candidiasis and malignancy.
Method: This test is based on the concept that pathological changes in the body will be reflected in alterations in electrical charge; changes that can be detected by Vega machines. The patient holds a negative electrode in one hand, and the positive electrode is applied to acupuncture points on the fingers or toes. A food extract in a sealed glass container is brought into the electrical circuit. A reduction in current is interpreted as showing a sensitivity to that substance. Children are assessed by testing the parent first, and testing is repeated with the parent holding the child's hand.
Evidence: This method has no established scientific basis. The results are not reproducible in blinded studies, and do not correlate with results from conventional testing.^1,4,5,8

Summary
None of the alternative diagnostic techniques have been proven able to distinguish between healthy and allergic subjects or to diagnose sensitisation.^1,9 Therefore, to date, no complementary or alternative diagnostic procedure can be recommended as a meaningful element in the diagnostic work-up of allergic diseases. This is especially true for food allergy.⁵

The only proven diagnostic aids are the serum-IgE test, skin prick test, and elimination diet with properly performed oral food challenges; these tests should be used in conjunction with a thorough clinical history, physical examination and possibly a food-symptom diary. A number of other investigative techniques are being evaluated in research facilities and may play a role in specific instances: e.g., CAST test, BAT test. Health professionals should alert patients about the risks of alternative tests:

• The tests are often undertaken by medically unqualified staff.
• The methods of testing are inappropriate for severe food allergy.
• Fictitious disease theories may be created.
• The resulting diagnosis will most likely be inaccurate.
• The tests are not accurately predictive, and most do not give reproducible results.
• Inappropriate and unbalanced diets may be recommended. It is often suggested that a large number of foods be avoided for an indefinite period of time, with little or no adequate dietetic review.
• There is continual failure to recognise and treat genuine disease.
• The tests are often expensive.
• The tests delay effective diagnosis and treatment.
• Physical interventions are often advised when psychosocial factors are the source of symptoms. This can impact on employment and social functioning.
• The test can lead to malnutrition and disturbed growth in children, unintentional weight loss, food phobias, frustration and anger when things do not improve, disruption of lifestyle and a poor quality of life.^1,5,9,10

Many supporters of controversial procedures have implied that their tests have been clinically proven and accepted. Therefore, it becomes the responsibility of health professionals to educate patients and to make informed decisions themselves.³

Why do these tests sometimes appear to work if there is a food allergy?
Some food allergens are very common, and in the case of true food allergy in a patient, inclusion of common allergens in a test may result, through sheer chance, in one or two correct allergy diagnoses . However, there is a great risk that a number of foods may be eliminated from a diet unnecessarily. Many of these testing practices may also result in a positive placebo response. The placebo responses in a minority of patients cause needless costs and confusion for the majority of patients.

C. Comments by our editors

Prof Janice M. Joneja Ph. D., RDN There are numerous unorthodox and unproven tests available for “food allergy diagnosis”, which frequently lead unwary consumers into the type of situation discussed in this case study. I have seen many patients who have run into great difficulties such as weight loss, nutritional deficiencies, food phobia, not to mention financial hardship, in their search for answers to their chronic health problems. It is so easy to blame food as a cause of chronic illness, as the body is constantly exposed to this “foreign material”. And, importantly, deciding on the substances that enter one’s mouth is probably the only thing in life over which a person has complete control. I have encountered at least one patient who mortgaged her house and ran up the debt on her credit cards to the maximum in order to enter a clinic in Mexico for intravenous hydrogen peroxide treatment in an effort to cleanse her body of the toxic residues from foods that had been diagnosed as the causative factors in her chronic ill-health. The fact that she came to me for assistance with her still-persistent symptoms indicates that the diagnosis was flawed and the drastic treatment did not help! Not so extreme perhaps are the patients who have been on complex rotation, or diversified rotary diets in an effort to reduce their exposure to the numerous “allergenic foods” (diagnosed by tests such as analysis of their blood for the presence of food-associated IgG) and to consume sufficient food to stay alive! Rotation diets have never been proven to be an effective means of management of putative food allergies by any evidence-based research studies. In the end, the only way to determine the extent to which foods are contributing to a person’s symptoms is elimination and challenge. The suspect foods are removed for a prescribed period of time (4 weeks is considered optimum). Each eliminated food is then reintroduced in a dose-regulated sequence and any symptoms recorded. Details of this procedure can be found in, Joneja JMV. “Dealing with Food Allergies”, Bull Publishing Company, Colorado 2003. pp 320-461

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D. References
1. ASCIA Position Statement: Unorthodox Techniques for the Diagnosis and Treatment of Allergy, Asthma and Immune Disorders, 2007. (For more references on the topic, please visit http://www.allergy.org.au/pospapers/unorthodox.htm)
2. Senna G, Gani F, Leo G, Schiappoli M. [Alternative tests in the diagnosis of food allergies] Recenti Prog Med. 2002 May;93(5):327-34.
3. Metcalfe DD, Sampson HS, Simon RA. Food allergy: adverse reactions to foods and food additives 3rd edition. Blackwell Publishing, 2003. Unproven Methods of Diagnosis and Treatment of Food Allergy
4. Frieri M, Kettelhut B. Food Hypersensitivity and Adverse Reactions. A Practical Guide for Diagnosis and Management. Marcel Dekker, Inc. 1999
5. Niggemann B, Grüber C. Unproven diagnostic procedures in IgE-mediated allergic diseases. Allergy. 2004 Aug;59(8):806-8.9. Passalacqua G, Compalati E, Schiappoli M, Senna G. Complementary and alternative medicine for the treatment and diagnosis of asthma and allergic diseases. Monaldi Arch Chest Dis. 2005 Mar;63(1):47-54.
6. Pothmann R, von Frankenberg S, Hoicke C, Weingarten H, Ludtke R. [Evaluation of applied kinesiology in nutritional intolerance of childhood] Forsch Komplementarmed Klass Naturheilkd. 2001 Dec;8(6):336-44.
7. Ludtke R, Kunz B, Seeber N, Ring J. Test-retest-reliability and validity of the Kinesiology muscle test. Complement Ther Med. 2001 Sep;9(3):141-5.
8. George T Lewith, Julian N Kenyon, Jackie Broomfield, Philip Prescott, Jonathan Goddard, Stephen T Holgate. Is electrodermal testing as effective as skin prick tests for diagnosing allergies? A double blind, randomised block design study. BMJ 2001;322:131-134
9. Passalacqua G, Compalati E, Schiappoli M, Senna G. Complementary and alternative medicine for the treatment and diagnosis of asthma and allergic diseases. Monaldi Arch Chest Dis. 2005 Mar;63(1):47-54.
10. Wright T. Food allergies: enjoying life with a severe food allergy. Class Publishing, London, 2001.

E. CPD Questions (For South African dietitians only. Australian dietitians: where you have relevant learning goals, CEU hours related to this resource can be included in your APD log.)

PLEASE ANSWER ALL THE QUESTIONS
(There is only one correct answer per question.)

1. True of false: Cytotoxic testing (or ALCAT) is widely accepted by allergy societies throughout the world for routine allergy diagnostic purposes.
a. True
b. False

2. True or false: There is no credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, nor that IgG antibodies cause symptoms.
a. True
b. False

3. True or false: Iridology is based on the concept that a person's state of current and past health can be diagnosed from the color, texture, and location of pigment flecks in the eye.
a. True
b. False

4. True or false: It is suggested that the use of Kinesiology as a diagnostic tool is not more useful than random guessing.
a. True
b. False

5. True or false: A significantly different benefit was achieved from the neutralising solution of the oral provocation and neutralisation concept, compared with placebo.
a. True
b. False

6. True or false: The pulse test claims to indicate allergy to a food if an increase in the pulse rate of greater than l0 beats per minute after eating the food is experienced.
a. True
b. False

7. True or false: The Vega test works as follows: The patient holds one (negative) electrode in one hand, and the positive electrode is applied to acupuncture points over fingers or toes. A food extract in a sealed glass container is brought into the electrical circuit. A reduction in current is interpreted as a sensitivity to the substance.
a. True
b. False

8. The only proven diagnostic aids for allergy are:
a. Serum-IgE test & skin prick test
b. Elimination diet with properly performed oral food challenges
c. Thorough clinical history & physical examination
d. Food-symptom diary
e. All of the above

9. True or false: These unconventional tests are often undertaken by skilled medical staff, resulting in diagnosis which will most likely be accurate.
a. True
b. False

10. True or false: One of the main drawbacks of these unconventional tests is that inappropriate and unbalanced diets may be recommended, which could lead to malnutrition and disturbed growth in children, unintentional weight loss and food phobias.
a. True
b. False

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Unconventional allergy diagnosis
CEU Reference number: DT/A01/2007/00110

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This issue was sponsored by Abbott Laboratories S.A (PTY) LTD All Abbott products are lactose and gluten free Tel: 011-8582054