August 7, 2023
Section I
Asthma, Allergies and Nutrition - The Story Part V
THE NUTRITIONAL STUDIES
THE CASE
Case presentation: DM is a 12 yo caucasian male who presented to integrative pediatric clinic for the first time at age 8 years with the chief complaint of moderate persistent asthma and allergic rhinitis. His past medical history relates one to three severe asthmatic flairs per winter requiring steroids and overnight hospital stays over the past few years. He had relatively mild disease in between major flares and was well controlled with a high dose inhaled corticosteroid making it difficult to predict these severe respiratory events. His mother brought him to our clinic for a different approach since they had failed to stop the flairs over the last 5 years.
His past medical history is notable for a term normal vaginal delivery. He was exclusively breastfed until 6 months of age and had no history of milk protein or food intolerance as an infant. He had no atopic dermatitis or gastroesophageal reflux, (GERD) concerns. His first wheezing episode occurred at 18 months old with a viral lower respiratory tract infection.
His past family medical history is significant for a father with allergic rhinitis, atopic dermatitis, GERD and asthma. His environment was notable for dog exposure at home, carpeting in his bedroom as well as many stuffed animals on his bed that he plays with. There were not any noted social or spiritual concerns with his family. There were no local toxic exposures. A thorough environmental history could not elicit an intermittent cause for his flairs.
His dietary history is primarily whole foods and vegetarian. Little to no junk food is consumed by his family. His immunizations are up to date.
Medication: Qvar inhaler 80 mcg 2-3 puffs with spacer twice daily, Albuterol inhaler 2 puffs with spacer every 4-6 hours as needed, pataday ophthalmic drops 1 drop each eye daily as needed.
His laboratory testing noted normal pulmonary function testing in the mid-summer time when he is relatively asymptomatic. Micronutrient and antibody evaluations were as follows: serum total IgE high 499 kU/L (<=280 kU/L); allergic IgE antibody to cat dander, all three dust mites tested were high; all other specific IgE serum testing negative; skin testing was positive for dog, cat and dust mite ; 25OH vitamin D 35 ng/ml (30-100ng/ml), RBC zinc 10.3 mg/L (9.0-14.7); serum IgG testing was positive for wheat 3+ (0-3 scale), egg white and yolk 2+ and 1 + for legumes (soy, beans) and dairy. He did not have serum IgE food testing performed as he had no immediate type food reaction history. His mineral levels are low normal and considered insufficient for optimal function.
Physical exam noted only allergic shiners and a pale and mildly boggy nasal passageway.
He was placed on an elimination diet for the three main offensive foods: dairy, egg and gluten. He was asked to rotate legumes and limit their consumption. He was started on an herbal medicine twice daily, D Hist junior, which is a blend of stinging nettles, quercetin and bromelain. He began RAW probiotic 40 billion cfu daily, 1 gram of marine fish oil daily, zinc picolinate 30 mg every other day and magnesium citrate 100 mg twice daily. He was also counseled to get 20 minutes of direct sunlight daily and exercise as much as tolerated.
Over the subsequent 12 months, he was able to go the entire winter without a single serious asthma flair despite four upper respiratory infections. This was a first for him. His allergies remained somewhat of a problem, however, the family was reluctant to remove the dog from the home or start sublingual allergy therapy. Over the subsequent 12 months he was able to wean off of his inhaled steroids. He never required another admission to the hospital or visit to the ER for his asthma. By year two he had added eggs back into his diet with no concern, but he remained off of gluten and dairy because he feels better off of them. To this day he is symptom free from an asthma standpoint and well controlled on D Hist Jr for his allergies. He only takes a daily probiotic and fish oil as maintenance therapy to date.
This case illustrates the dietary pathways that can be taken to achieve a desired outcome. In this case it was more the avoidance of certain foods than the addition. Many of my other cases are a combination of avoidance and addition of many foods in the vegetable and fruit category.
Based on the totality of the available data as presented over the last 10 weeks, we see a pattern of eating that can have a profound effect on human inflammatory type diseases like asthma. Following a Mediterranean or Blue Zone style diet is correlated with less disease, less medicine use and overall better sense of well-being. The principles of an effective eating pattern to reduce the risk of inflammation and asthma are as follows:
- Consume 10 or more servings of fresh whole vegetables and fruits daily
- Rotate foods constantly and eat seasonally where possible
- Drink lots of fresh clean water daily
- Aim for 40 or more grams of fiber a day. Beans and berries are a great source of fiber
- Eat avocados, nuts and seeds daily
- Consume small oily fish a few times a week. Try salmon, mackerel, sardines and trout
- Severely limit processed food, especially those laden with flour, sugar and processed oils
- Reduce your consumption of saturated fats from animal or vegetarian sources
- Monounsaturated fats like extra virgin olive oil are prized for health benefits
- Avoid all trans fats like margarine and vegetable shortening
- Do not eat foods that have ingredients that you cannot pronounce or understand
- Consider timed eating patterns for antigenic bowel rest, i.e. only eat between 12pm and 8pm daily
- Avoid foods that are food allergy or sensitivities based on testing or elimination trials
- Be mindful and eat slowly maximizing chewing activity to effectively break down food (Julia et. al. 2015)
As with all things in life, it is about balance. A balanced diet is critical to a healthy disease outcome.
LAST THOUGHTS
Now that we have thoroughly explored nutrition and asthma in humans, what other adjunctive therapies can be leveraged for better outcomes?
Simply put, think of asthma or allergies symptoms as a glass of water overflowing. If the cup overflows, then you have disease symptoms like sneeze, congestion, itchy eyes, wheeze, shortness of breath, cough and so on. Therefore, it would make sense that we reduce the volume of water in the cup to reduce the disease burden. This helps to rebalance the immune response.
Other than the previously discussed nutritional and micronutrient changes, what can we do?
First - Avoid known triggers of disease. If you are allergic to dust, cat or dog hair, pollen, etc, learn how to mitigate these antigenic triggers in your local environment. Visit websites like www.aaaai.org or my good friends at allergy choices. Here are some basics from Dr. Cipriani's article in Frontiers of Pediatrics:
House Dust Mite
- Use bed-encasing for mattress and duvet/pillows
- Wash bedding weekly in hot water and dry in a heated drier
- Remove dust mite reservoirs (i.e., toys and stuffed animals, carpets)
- Reduce indoor humidity (less than 50%)
- Vacuum with a HEPA filter bag
- Remind that chemicals to kill mites or denature proteins have a modest effect
Pets
- Remove pet from bedrooms and everywhere the child spends a lot of time
- Clean accurately upholstered furniture, walls, and carpet
- Remove upholstered furniture and carpet if possible
- Encase the mattress and pillows with bed encasing
- Keep the pet clean with frequent washes
- Use a HEPA air filter
Insects
- Inspect to detect hiding places debris (grease, kitchen) and identify food sources
- Store food in sealed containers
- Exterminate with pesticides or bait traps
- Remove clutter and seal holes or cracks in the home
Mold
- Reduce indoor humidity (less than 50%)
- Remove contaminated carpets, wallpaper, and woodwork
- Treat washable surfaces with detergent and water and then dry completely
- Repair water leaks
Pollen
- Keep windows closed
- Bath to remove allergens from hair and body
- Consider to use HEPA air filtration
- Consider same principles for outdoor mold avoidance (Cipriani et. al. 2017)
Second - Consider subcutaneous immune therapy allergy shots (SCIT) or sublingual immune therapy (SLIT) to retrain the immune system to recognize these triggers as benign actors and not trouble makers. I prefer to go the SLIT route as it is much cheaper, requires less family time driving to the office weekly for shots as all doses are administered at home and works equally well. The only hiccup remains that SLIT is not covered by most insurances (cannot understand why)! The cost is very reasonable for the benefit outcome. We have offered this desensitization route for years with excellent results. Find a provider link
Third - always take your medicines as directed until the prevention interventions kick in and your provider team agrees to wean the meds. Asthma flairs can and will kill some patients every year. Please take this very seriously. I have seen this happen. Compliance in medicine is a major key to positive outcomes.
The asthma story finishes today,
Dr. M
Cipriani Frontiers in Pediatrics Article
Julia Nature Reviews Immunology Article
