Nutrition Experts Podcast

“I am an Allergy Specialist dietitian, dealing with children and adults diagnosed with food allergies, ranging from Food Protein Enterocolitis Syndrome, Eosinophilic Gastro-intestinal diseases, other non-IgE mediated food allergies and IgE mediated food allergies. I also have a particular interest in the role of nutrition in the prevention, diagnosis and management of allergic diseases.

I obtained my BSc Dietetics degree from the University of the Free State, South Africa. Following from this, I obtained a Post Graduate Diploma in Allergy and a PhD (2007)  from the University of Southampton, United Kingdom.

I have had the wonderful opportunity of working in South Africa, the United Kingdom and in the United States. I am a  registered as a dietitian (RD) in all these countries. I currently work as an Assistant Professor of Pediatrics, Section of Allergy and Immunology at the Children’s Hospital Colorado and University of Colorado Denver School of Medicine. Previously, I was appointed as an Assistant Professor/Dietitian at Cincinnati Children’s Hospital Medical Center.

I have been one of the founder members of this International Network of Dietitians and Nutritionists in Allergy. I am also a member of the American Academy of Asthma, Allergy and Immunology (AAAAI), European Academy of Asthma, Allergy and Clinical Immunology (EAACI), British Society of Allergy and Clinical Immunology (BSACI) and the Allergy Society of South Africa (ALLSA).

I enjoy writing and I have had a number of publications in international journals.  I regularly get invitations to present at in covering a range of topics relating to nutrition and allergic diseases.

One of the highlights of my career has been my appointment to the Expert Panel of the National Institutes for Allergy and Infectious Diseases Peanut Allergy Prevention Guidelines, making me the only dietitian that has had presentation on official US and European food allergy guidelines.

I am forever indebted to the team at the David Hide Asthma and Allergy Centre on the Isle of Wight (UK) who has taught me so much…but I am still learning, every day from amazing colleagues around the world.”

Mathea Ford [00:00:29] Hi there! It’s Mathea. Welcome back to the Nutrition Expert Podcast. The podcast featuring nutrition experts who are leading the way using food starts today right now with our next guest. It’s great to have Carina Venter on the show today. Carina welcome to Nutrition Experts.  

 Carina Venter [00:00:43] Well thank you and thank you for having me. And you know there’s so much misinformation about food allergy out there that I’m quite excited to be part of this podcast to at least try and answer some of the questions or perhaps correct some of the misconceptions out there.  

Mathea Ford [00:00:59] Great! I’m excited to have you on the show and to share your expertise about allergies with my audience because I think it’s one of the things that there’s a lot of information that unless you’ve put it all together it’s probably hard to pass out the right things. So, tell my listeners a little more about you and what you do.  

Carina Venter [00:01:18] So, my official title is Assistant Professor in Allergy and Immunology, Department of Pediatrics at the University of Colorado. But I do consider myself an allergy specialist dietitian and I studied my first degree in dietetics in South Africa where I am originally from. I then moved to the United Kingdom where I did a postgraduate with my PHC in Allergy and Immunology. After that we moved to Cincinnati where I did two and a half years focusing on your eosinophilic esophagitis. A particular type of food allergy and then now located in Denver where we definitely planning to stay for the long term working in the area of food allergy prevention again which really is my passion.  

Mathea Ford [00:02:05] In case the audience didn’t notice you specialize in food allergies. So, what got you interested in that specific area? What made you want to get your degrees in allergens and immunology? That type of stuff.  

Carina Venter [00:02:18] I actually was a dietitian who loved working in nutrition support and you know in intensive care units but it so happened that we moved to the Isle of Wight where my husband got a position as a physical therapist and Allergy Specialist dietitian resigned or she because of an age and they needed to replace her. And so they asked me if I’d be happy you know to cover their food allergy clinics which I very reluctantly agreed to. But as you know my nature is often about the third clinic really not understanding anything the doctor was saying about sensitisation but not Clinical Allergy and Clinical allergy in the absence of sensitization and desensitization. I decided to enroll into the master’s degree in Food Allergy at the University of Southampton and I just totally fell in love with it. I happen to have sisters with many different kinds of food allergies also nieces and nephews with allergies so it’s definitely been something that I’ve seen in my whole family and my own family, experienced in my own family. But once I start to learn more about all the mechanisms involved in an allergy I just totally fell in love and I haven’t never looked back.  

Mathea Ford [00:03:34] So, let’s talk about in general how our food allergies diagnosed? Because I know people sometimes say they have a food allergy sometimes they say they have an intolerance. What is kind of the difference and how are they diagnosed?  

Carina Venter [00:03:47] Broadly speaking there are two types of allergies particularly in terms of food allergy. So, we have the mediated food allergies which we refer to as IgE-mediated food allergies and they normally occur within two hours of eating the food. Normally, it happens quite quickly five to 20 minutes. For these allergies, we do have taste either a skin prick test or we can do a black test the specific IgE test. But these test really should be interpreted by an allergist so I’d say my one crucial measure is I want to get across today is don’t self–diagnose. If you think you’ve got a food allergy you need to get the appropriate testing done and it needs to be done and interpreted by an allergist.  

Carina Venter [00:04:32] Then, we have the non-IgE mediated allergies which are more the delay type. They have very complex names such as eosinophilic esophagitis which is really over time food allergens causing inflammation in the esophagus and the children start having problems with growth faltering, they can’t swallow and they may have abdominal pain really depending on their age. These types of allergy eosinophic esophagitis can only be diagnosed by an endoscopy done by gastroenterologists. So, and some testing may or may not be performed to allergies it’s normally a team approach looking after these kids. So, bottom line for adults again if you think you may have one of these swallowing problems or allergies causing swallowing problems get to see an allergist and a gastroenterologist, get a good diagnosis which they can then manage with diet and medication. The other types of non-IgEfood allergies are called Food Protein Induced Enterocolitis. I’m fascinated by the disease. I see many of these young infants in clinic. I absolutely love dealing with these families and that is really profuse vomiting cause about oh occurring about two hours after eating a typical food. So, things like rice or mango or banana is also caused in some cases by milk or soy milk and the children often end up in the E.R. because they get totally dehydrated and need to get I.V. fluid. So, that’s sort of like the two main non-IgE mediated diseases. Then we get other kinds of non-IgE mediated allergies affecting the gut. Some people call them enteropathies. Some refer to as intolerances but really using the word intolerance in these cases is incorrect because they’re all mediated and caused by the immune system. And so really, we should be talking perhaps about delay type milk allergies or delay type egg allergies supposed to milk intolerances. I don’t actually deal that much with intolerances but the National Institute of Allergy and Infectious Diseases or NIAID as we do factory in the United States clearly say that these are foods trigger symptoms which is not mediated by the immune system. That could be perhaps foods causing irritable bowel syndrome or it could be foods causing lactose intolerance. But we don’t typically deal with these cases in an allergy clinic. So, we see the broad spectrum of the immediate and delayed type allergies.  

Mathea Ford [00:07:12] So, you mentioned food protein. I didn’t hear the rest of that food protein type of allergies? What was that?  

Carina Venter [00:07:18] Protein Induced Enterocolitis Syndrome. And we have abbreviation some people call it PIES and some calling FPIES but it’s basically FPIES food protein induced enterocolitis syndrome. It can be very very distressing for mothers. I’m dealing with this you can imagine the first time you give your baby baby drops or the second or even the third time and this child just starts vomiting and just do not stop until eventually you end up in the E.R.. So, a lot of food fear and delayed introduction of foods in these families that we have to deal with and quite understandably so.  

Mathea Ford [00:07:57] So, what are the allergies that in the United States for example that we put on labels that are the most common?  

Carina Venter [00:08:04] So, we have that the eight main allergens in the United States. And now this is going to be a test for me because I always seem to get one or two. But here we go. It’s milk, egg, wheat, soy and then crustacean shellfish. So, not mollusk but good or crustacean shellfish then normal fish and then peanuts and tree nuts. Quite interestingly the list of three nuts is the longest list I’ve ever seen in the world with number of foods or things listed as tree nuts like and that we probably would never eat but one of the problems is that coconut is also on this list of tree nuts. I think the FDA are currently thinking about removing this because we do not see coconut allergies amongst the tree nut allergies in clinic. And so I spend a lot of time explaining to patients that may be allergic to one or two tree nuts or even older tree nuts that even though coconut is clearly indicated as an allergen on food labels. We do not consider it to be a main allergen and they can say if you consume these.  

Mathea Ford [00:09:13] So, how are those diagnosed? Just by go into the allergist or like you said go into the E.R. and then going through a medical kind of… Is it more of an elimination or is it you said mentioned that IgE mediated ones have blood tests but the other ones don’t?  

Carina Venter [00:09:31] The other ones don’t. There is no blood test that’s going to tell you you have eosinophilic esophagitis triggered by milk and there’s no blood test that can tell you that you’ve got this fpies to get by oat. So, it’s basically in terms of eosinophilic disease, we do the endoscopy we confirm that this is what they have. And then we can take either milk or wheat out of the diet. Sometimes we take milk, egg, wheat and soy out or we could do milk, egg, wheat, soy, peanuts and tree nut so its either two foods, four foods or six foods. Some doctors start at the two and then do four and then six if needed some start at six. We clearly have a varied in-depth discussion with families to find out from them as well. Do they want to start with two or perhaps just one in which case it will be milk or do they want to start taking six out? And then we take the foods out about six to eight weeks. We do a repeat endoscopy to see if eosinophils have gone down. We normally count on them in a microscope and if they less than 15 in the area that we can see we call it the high powered field but less than 15 in that area. We say that we’ve got the remission and we’ve got control of the disease and then the difficulty start because then we put the foods back one at a time and again depending on the gastroenterologist and allergist we probably would do an endoscopy six weeks after we put each food back to see if that is the food that’s that’s causing the inflammation or whether it’s perhaps smoke and we treat getting it. Clinically, I just want to say that quite often you know we start putting milk back in the kid’s diet and the endoscopy is booked for six to eight weeks from now but after about three or four days those kids really get on well they start vomiting again not as profusely as the kids with FPIES that they get tummy ache, they lose all appetite. Which case we may not just do an endoscopy straight away we just say “let’s take milk out again you’re clearly highly symptomatic and we’re not going to put the child through the trauma of having six weeks off of food that’s clearly making him unwell.” So, sometimes in a lot of time in allergy you know it’s what the textbooks say and then there’s the clinical common sense and I’d say we definitely work closely with our families to see what’s best. So that’s that eosinophilic disease and then for the FPIES, it’s really just a medical diagnosis. We we ask which food they ate we clearly saw the symptoms we get the report from the E.R. We would not then suggest that they go try the food at home again. Normally, if we are convinced that it was oat or soy or milk we would avoid it for about six months and then we always bring them back and introduce that food in hospital because it is not something you want a mom to do at home and get to keep you know severely ill. We normally put I.V. fluids into the arms of the kids when they come in to get the food reintroduced. And again the six months could be 12 months, it could be three months. It really just depend on each case. So, no black test with a non-IgE ones and for the IgE ones the immediate ones, we have a blood test or skin test but always needs to be interpreted by an allergist. A positive test does not confirm an allergy without having a good history taken by an allergist.  

Mathea Ford [00:12:54] What concerns should the public have about the food allergies? Are they increasing? What is what is going on?  

Carina Venter [00:13:00] Food allergies are definitely increasing. I think you know I’ve published a lot in this area. I think the kind of food allergy and whether that particular food allergy is increasing is country dependent. So, our data in the United Kingdom showed that food allergy tripled in kids born in 199 versus kids born in 1997 but then it seemed to plateau looking at our kids born in 2001. And that’s really the beauty from the Isle of Wight is because we have these cohorts of children that we can follow up over generations. And so that’s data from the United Kingdom. And you know whereas in the States it seems that peanut allergy is still increasing. We’re beginning to see more Sesame allergy in the United Kingdom. We’ve been dealing with Lupin allergy in Europe a lot. Lupin is a beautiful purple flower and they mix the seed of this purple flower and they put it in flour when they make pastries or bread because it makes it light and puffy. So, we’ve been seeing a lot of lupin allergy in Europe when when I worked and lived there and we never saw lupin allergy in the United States when I first arrived here four years ago. But you can now buy bread in the normal bread aisle in King Soopers that’s got Lupin in. So, we are now beginning to think “Are we going to see more Lupin allergies? Should we start testing these kids for Lupin allergies? So.” I definitely it’s increasing but I think it’s very country specific what we should be concerned about. And also interestingly I was in Thailand last week, we read allergy is the biggest problem and we almost never see immediate dark wheat allergy in the United Kingdom. You get one out of a thousand kids. And it’s also probably not one of our main concerns in food allergy clinics and children in the United States even though we see it. So, again very much country specific with wheat allergy rates escalating at the moment in Thailand.  

Carina Venter [00:15:03] So what should the public be concerned about? I think I spent my life telling pregnant women or mothers that they haven’t done anything wrong and there was nothing else they could eat then and there was nothing that they should not have eaten. It clearly lies in the food we eat. Okay? But we we don’t really know whether it’s because we’re eating more ultra processed food. Or perhaps because we eat more barbecued foods. I can tell you all that the immune interactions of eating all these foods but. And when we do mouse models you know we get beautiful data showing perhaps we should eat less burgers but we just don’t have that data in humans. So, I think what I would like to say is this definitely an answer in food but we just don’t know what the answer is. The one answer we definitely have about food and a good friend of mine George just do a bit the LEAP study learning clearly about peanut in the United Kingdom where they clearly showed that introduction of peanut in the first year of life prevent peanut allergy and so of course from that followed the NIAID guidelines of which I was one of the panel members with instructions. If you want to read more about it we will talk about my blog a bit later. But it’s on my blog or on the NIAID website about how to introduce peanuts in the infant’s first year of life. And for parents that’s really concerned they may have another kid with a peanut allergy or they may just be concerned about the allergies will stop. They can always go and see their primary care physician or an allergist that could help facilitate this introduction of peanut. But that’s the one fact we have, he said you give peanuts early in the first year of life and you continue to eat it and you prevent peanut allergy up to the age of five. It doesn’t affect other food allergies. So, you can eat as many peanuts as you like it’s not going to stop you from developing eczema, egg allergy or rhinitis unfortunately. So, I think you know allergen specific, we’ve made a big U-turn. We used to be scared of giving these allergenic foods to young kids. We’re not scared anymore. We actively advocate you know early introduction of peanut and in terms of the other ones we say once you commit to weaning get the allergens in you know. We can set the clock to say fish has to be in by seven months and egg has to be in by 8 but definitely once you start with weaning foods, these foods should not be avoided without any good reasons and as the family eat these foods it should be introduced in the infants’ diet. So, really pregnancy I have no advice at the moment. Breastfeeding I’d say please breastfeed for as long as you can. But I can tell the breastfeeding mom how to change their diet to make a breast milk any better for prevention of allergies. And then we have the early life where we know we need to get the allergens in. But other than the peanut specific data, we don’t have other really good good studies to refer to.  

Mathea Ford [00:18:10] So, what is it that makes introducing peanut early avoid the peanut allergy?  

Carina Venter [00:18:15] So you know I think if I can put it in non immunological forms it’s sort of like just saying to the immune system it is okay. You know it’s not a foreign antigen like you know some other bad that he has to fight. Actually, the same immune system that fights worm infestations causes allergies so it’s really almost like saying to the immune system “it’s okay. You can digest and absorb it. This is not not a worm trying to come and live in your intestines.” But on a more scientific level. And when children have eczema particularly the children with eczema they have a lot of inflammation in their skin. And if they come across that allergen via their skin, the immune cells that drive that reaction is almost always. I want to say causing allergies is perhaps a strong word to say cause but what we are trying. But if you eat the food via the oral route and the allergen gets into your gut, the immune system that’s driving that is more a toleregenic immune system as we call it’s one that says “it’s okay. Let’s digest and absorb.” So, the reason we want to get allergens into children early is because by getting it via the oral route into them rather than via the skin is going to help them to tolerate the food to not be allergic. And that’s this. So, the LEAP study was really done in children with eczema. So, we have good data but when we had to write and I had guidelines it was said that you know huge discussion about it. So, is this relevant for kids with eczema only or are we going to say all kids need to get the allergens in? And pretty much all the guidelines across the world is now in agreement that it’s not just the kids with eczema. Every kids that we see we’d like to get the allergens in and keep it in and particularly in relation to peanut but again on my website I have got very practical guidance on how to feed peanut and then what to do with the allergens. How do we get egg and soy and fish into young infants.  

Mathea Ford [00:20:24] I was going to ask you is avoidance primary way we prevent food allergies but it sounds like that’s not the right way.  

Carina Venter [00:20:30] And actually you know it’s fascinating because when I started my career on the Isle of Wight, in Europe they often refer to it as the mecca of allergy prevention. And of course we did the very first study in the world where we told pregnant and breastfeeding women to avoid or to exclude the allergens from their diet and then not to give the allergens in the first year of life. And that is now almost 30 years ago. So, and it didn’t work. And so you know we’ve come a long way in the allergy world where every now saying we don’t want to avoid we want to eat. And getting back to the pregnant woman as well, as much and the breastfeeding woman the advice is not as clear as say you must eat allergens but we do clearly say don’t avoid. So, we’ve definitely stepped away from don’t avoid anything because you think it will cause allergy. Having said that I say to the pregnant lady that I see “if you absolutely detest peanut and you cannot eat it, the evidence is not good enough to say you must eat peanut. You know it’s okay. If you cannot eat it and you don’t like it, let’s wait until the guidance is strong enough to say you really should be eating peanut.”  

Mathea Ford [00:21:43] So is it normal for a child or a person with one allergy to have multiple allergies?  

Carina Venter [00:21:49] I think that is one of the biggest debates in the world. So, clinically I’d say we see more and more kids with more than one allergy. We are also trying to put a case series together where you know we used to see kids with UE that eosinophilic disease and then we used to see the kids that’s got the advice and then we used to see the kids with the immediate type allergies. Now, we’re beginning to see one child that’s got all three. So, they may have this eosinophilic disease, the inflammation in the esophagus caused by milk. They may have immediate type peanut allergy and they may have this profuse vomiting or FPIES caused by oat. And so not only do we see more and more kids with multiple food allergies we see all these multiple immune reactions with within one child which we don’t think we used to see before. The problem with prevalence data is that and I’ve done that myself you know so now you have a one year old that’s got you know a peanut and egg and a soy and perhaps a wheat allergy and that to publish your data you have to put these kids through blind challenges which means do challenges for every food. So, to really put a kid through 8 challenges just say you can count them once in a paper you know who’s ethically, I don’t think acceptable and so like in my studies I might have done the milk and the egg challenges blind. And so, I had really good data to show this kid has gotten milk and egg allergy. We also put in the paper that we think they’ve got the soy and wheat allergy but because we didn’t bring them in for these blinded challenges. Scientifically it was not good enough. And so, I think this is why we just don’t have good enough studies where we’ve put these poor kids with multiple food allergies through all these very many challenges but clinically definitely, we see more and more kids with more than one allergy and more than one immune mechanism driving all the different ones.  

Mathea Ford [00:23:43] And so why do you think that they have multiple allergies instead of like you said they can get three different kinds of allergies type thing?  

Carina Venter [00:23:52] I think you know you have two things that I’m looking at at the moment and many other people are doing much better work than me is really understanding the microbiome. And you know and how the microbiome is driving this cascade of immune diseases. So, it may again come back to the food we eat. You know that may be affecting the microbiome which is leading to just more like I almost want to say an overactive immune system. And then the other thing also is that clearly you know with this rising allergy seeming in the last 20 years. We know genetically humans haven’t changed but epigenetically, we might have changed. And so again you know in simple terms, proteins and carbohydrates can slightly change your DNA. So, we don’t change your genetics but we do change sort of like let’s say carbohydrates tail so perhaps protein tails that attach themselves to the gene. So, it’s a very simplistic way of saying this. And that has definitely changed over the years. And so that may silence some of your genes or it may actually make some of your genes more active and we think that that once again could be leading to this overactive immune system. There are many things that can affect your epigenetics and your microbiome other than food could be air pollution. Some of my colleagues are actually just looking at the vapors that you inhale from your sofa and how that affects your genetics. Your obesity levels that can affect your epigenetics and it affects the same signals in many ways as the ones causing allergies. So, it’s really where we sit, what we breathe in, what we eat, how active we are, how obese we are. So, there’s this many different factors that that we have to take into account when we try and figure out why do we see more allergies. Why are they more complex and why are they perhaps more severe?  

Mathea Ford [00:25:56] So, thinking about parents of maybe young children wanting to either avoid allergies or prevent food allergies. How do they how do they go about doing that? And I know you mentioned some early introduction stuff. But are there any other ways that you can prevent or avoid food allergies showing up?  

Carina Venter [00:26:18] This is what I would say to the family. I would say to the pregnant women I am hoping that one day I’ll prove just healthy eating in pregnancy helps prevent allergies. And so, I think in terms of pregnancy diet, eat as healthy as you can and if you have morning sickness and you can only eat dry toast for three months then it’s okay you know. But try and get on a healthy diet as soon as you can. I say breastfeed. This is low and little evidence to say that breastfeeding per say prevents allergies but it’s more protective for positive than negative. And we always want moms to breastfeed. And then the other interesting thing is and we don’t have these trials completed or very conclusive data is that we have to moisturize the skin off children because I explained to you that we now have eczema and they come in contact with the allergens it can cause allergies. So, we now say “look after your baby’s skin and let’s moisturize well” and so whether that needs to be creams or emollient or whether just putting some oil on it. You know we’re still studying but definitely look after your baby skin and discuss how to do that with with an allergist or dermatologists in this case and then we say don’t introduce solids before four months but from four months on if the baby’s ready to eat start introducing solid foods when they’ve had one or two foods then that is when we start introducing the peanut. And when we get them established on peanuts. For about two weeks then you can start introducing the other allergens.  

Carina Venter [00:27:54] Getting back to the peanut, for the kids with eczema. We we have sort of strict advice where we say try to get the peanuts in three times a week in a dose of 2 gram of peanut protein and it’s about the heat teaspoon of peanut butter to make it simple but they want the exact dosaging they can again go on the NIAID website or they can go on my webite where I’ve explained that my blog. So, that’s the peanut then we get the allergens in. Something else and I’m actually just I’ve just I’m just writing my paper it’s like right there next to me. We have one study published by Caroline Rogaine from Multicenter, a study in Europe where they showed that diet diversity. So, the more different foods kids eat in the first year of life the less likely they are to develop food allergy in particular in this one study. My data sort of like indicating the same but I still have to go through the interview and my paper needs to get accepted. But so, I also cited appearances. Don’t be scared of food. You know we’ve started weaning now we’re going to we’ve done the allergens that keep the diet varied you know. And once again you know many kids have and as we call it in England fatty eating behavior or in America they call about picky eating. I say “don’t get in the stress because they won’t eat tomato. It’s okay. But if they love food then feed the variety of foods that they like and love you know as often as you can. And don’t forget that sometimes the key test to eat foods up to depending on the paper you look at 13 to 20 times before they will accept the food. So, no keep the spinach for the first time and think this is amazing.” They got all their faces and spit it out but persevere. You know unless you can eat at least 20 times. Don’t give up. So, I think because I like to give parents a positive message about what to give and what to focus on on a more negative side, we could perhaps say don’t give too much commercial baby foods because they sterile so there’s no natural microbial load on the food. You know there’s not such a diverse range of food. We could say don’t give your kids  too much fried foods because our mouse model data show that giving too much fried foods can negatively affect the immune system but rather than giving them a list of what not to do I really try and focus on the good things in life and the things that we know more about and then off to the first year of life you know this is nothing much we know there’s some limited data showing that key to eat a Mediterranean lifestyle diet have less reason asthma but it’s not really being shown for things like eczema food allergy or rhinitis. So, again healthy eating, Mediterranean style eating you know if they love tomatoes feed that to them use olive oil if you can. If they love fish give it to them and they don’t like it keep offering it. Yeah so. So that’s the kind of things that I think families can do. And I’m not an expert in what we call environmental allergens so some people say having a dog is a good thing. But but that’s not my area of expertise so I wouldn’t venture on that.  

Carina Venter [00:31:17] You’re just all about the food? 

Carina Venter [00:31:18] Yes. And I love my dog so I’d like to keep a dog so I let you prove insensitive but like I said it’s not my expertise.  

Mathea Ford [00:31:28] Dogs are good for more than an allergy prevention. So. Yeah.  

Carina Venter [00:31:31] Definitely.  

Mathea Ford [00:31:33] So, you mentioned a little bit but what other research is promising in this area of food allergies that maybe people should be aware of and be on the lookout for?  

Carina Venter [00:31:43] I’m not myself involved in these studies but my my boss as I call him Dr. David Fleischer is very involved as on many allergists around the world that I know in what we OIT or oral immunotherapy studies. So, this is this may be a kid with a peanut allergy or a wheat allergy. Having said that I have been involved in some of the trials. So, we will give them grated peanut introduction in the hospital up to a certain dose and then we will ask them to go home and to continue to eat that amount of peanut let’s say for two to four weeks or six months or twelve months depending on the clinical practice in the study then they come into hospital and we give them a little bit higher dose and another little bit higher dose and they go home and they continue eating that. So that over time you can gradually induce tolerance to this food either the egg or the wheat or the peanut. All many private practicing allergists that’s already doing this and then I’m based on most academic centers we are only doing it as part of research studies. We’re not really just bringing kids into clinic and we feed them these allergens because you know there are risks involved in doing this and the majority of children that go through these trials of introduction will have a reaction at some point. But the good thing is that we can get them at least tolerant to a small amount. They may never get to the point where they’re going to eat a handful of peanuts or three Snickers bars but we can get to the point where somebody by accident put peanut containing sauce on their food know. That just taking a bite may not cause a reaction and they don’t have to be concerned about things that says may contain traces of peanuts or may contain traces of smoke. So, that’s a one–time oral immunotherapy where we literally feed them the food. Then the other trials that we are involved in, catch these trials so we place a patch containing peanut allergen. We know most about that but then you know we’re probably going to go towards egg and milk patches as well so that have the allergen on this patch which you put on the shelves. And I think back on. I haven’t actually placed there myself and they wear these for a certain amount of time and they come back and we do a challenge to see how much of the food they can tolerate with the patches in particular they never going to get to the point where they will eat the allergen but the patches can protect them from accidental exposure. So, somebody might have contaminated something and they definitely don’t have to then worry about making traces anymore. Like I said you know the patch trials are mainly we have good data for the peanut. My my boss Dr. Fleischer was first author of the paper in the middle of the American Medical Association about a month ago. And of course, with the patches we have less side effects. So, the kids don’t seem to have the reactions that they have with the oral immunotherapy.  

Carina Venter [00:34:53] How do you choose which one you want? Spend a good two hours with your allergist discussing you know your family circumstances. We look at things like how much support do they do? You know if you have a kid like mine that spends like six hours a day almost in a swimming pool, patches perhaps not the best option. So, we look at this sport. We look at where do you go on vacation. We look at how dedicated you are. Are you going to give that dose of peanuts every every time you’re supposed to? Or are you most suitable for a patch? How scared families are with treating accidental actions which we know we will get with the oral immunotherapy make so with the patch and also what they want at the end of the day. Do they want the key to be able to eat two peanuts? Or are they just concerned about the may contain traces eating food. So, these are really the things that the allergist can talk to you about and then families can make an informed decision. But I say this is the most exciting thing other than the early introduction of peanut you know is these studies showing us that we can change the immune system. The one trial that I am very biased. I love the trial. What they’ve done in Australia where they’ve given the kids peanuts the greatest introduction plus a probiotic and actually really great results. They are now doing a follow up of this study so because again you know perhaps there is a place for thinking can we fix the microbiome and we can fix the allergen intake and that together perhaps it might have a better and quicker effect than just feeding a probiotic or just giving them the allergen. So, in early days but exciting times and I really hope that we will get to the point where one day we can help all children who outgrow their energies to some extent.  

Mathea Ford [00:36:46] I think something that all of that discussion that we do you just kind of brought out about the trials made me think about how difficult is it to live with a food allergy. Is it easier now than it was before? Is it is it just a worry all the time is it?  

Carina Venter [00:37:04] How complicated is it to live with a food allergy that will really depend on on the family you talk to. You know I am when people say to me what what’s the biggest thing you’ve learned in working with food allergy for the past 20 years. As I say I’ve learned that every family has defined their comfort zone. And that comfort zone is very different for every family. I have mothers who would literally not go and feed that baby unless I read the labels of five products which I think is safe and they go home and they feed just those five foods for at least two weeks. And then so I see them regularly and it takes us a long time to get their confidence back to cook again you know adapt their recipes and then I get families where kids would have had a very similar reaction to the one, I was just talking about. But family is not concerned at all. They’re very laid back about it. They’re not concerned. I think you know it’s really up to every family to see how they’re based on to deal with it. But the standard advice we have to give every family is how to read labels, which foods are safe, which foods are good replacement foods. Give them an epinephrine prescription. Teach them how to use it and also teach extended family and friends if if that may be necessary. Just getting back to day to day living with food allergy. I’m not sure necessarily if it’s getting easier. There’s definitely more availability of allergen free foods. And more variety but I think that also leads to more label checking and getting a little bit more confused. We have a classic example yesterday when my husband was shopping and the lady couldn’t read very well and she said to my husband that her son is gluten, has celiac disease but she sees this is egg pasta. And so, can he just read because she thinks this should be fine because it’s made from egg. Well of course egg best still has the wheat in. He took it to the aisle which he could find the gluten free food. So, I think the more you know the more foods they are in the more new products coming out in many ways it could get more confusing. But I have to say that they are now and I don’t really want to mention the brands and number of an allergen free ranges where I can say to my patients if you go on that website every single thing you ordered will be free from all the top eight allergens. And they guarantee that on the website. So, for them at least there’s now some sort of safety haven which I didn’t have 10 years ago. So, I think in some ways easier I think in some ways more difficult. Quite frankly label reading is a nightmare. You know front of pack is not covered by their federal laws so you can put on the front of pack smoke free and then on the back it may say contain two types of milk proteins casein and beta lactic globulin. Legally, they’ve done nothing wrong because all that needs to be correct is the information that on the ingredient list. What you put on the front of back is fine. You know it’s not legally binding so some people may see on a label kosher friendly and think it won’t have milk in or it may say vegan friendly and think they may be no egg or milk in but if you check the ingredients it’s still in there. Another nightmare is I can talk rad labels forever. Peanut oil. So, we say to our patients they can have refined peanut oil but they can’t have their Expeller Pressed or the cold pressed peanut oil. But majority of products when they actually list peanut oil will not actually say which type it is. So, then you have to call that company to find out. So, in many ways getting easier but also still many questions.  

Mathea Ford [00:40:59] Yeah, I didn’t realize that a lot of like food restaurants use peanut oil to fry and that can be a huge issue obviously…  

Carina Venter [00:41:10] But you know I think again if if it was standard let’s say if all restaurants use the unrefined peanut oil like the Expeller Pressed then we could just say to our patients never eat anything in a restaurant that contains peanut oil. But the truth is that the majority of restaurants use that refined peanut oil which is perfectly okay. But it’s more like perhaps when you go to like a gourmet restaurant or go to Asian restaurant where they may be using that cold pressed oil so once again the patient needs to be detective. And like I say to them “always check, always ask. Never put anything in your mouth unless you’ve checked and you’ve asked.” Said that never goes away.  

Mathea Ford [00:41:54] So, thinking about just the general public or the listeners to this show what sort of information, how can they use the information we’ve talked about today in their day to day life? Whether they’re counseling patients or just going about their day.  

 Carina Venter [00:42:10] Okay. So, I’ll first do prevention. They know their management. I think I’ve summarized prevention very little we know about pregnancy, breastfeeding and early life. You know when you do meet parents that still trying to avoid any allergen ever created. And I think you’re in a good place to say now you know people don’t avoid these things anymore. Perhaps you want to go see your allergist or PCP to discuss introduction of allergenic food. I think if you have a friend with a kid with terrible eczema, get them to go see a dermatologist or an allergist because treating eczema early in life is probably one of the most important things we can do. So, that’s that. Then in terms of management I would say if you have a friend or a family member. That has an allergy you’re aware know exactly what they need to avoid ask them. That’s my number one thing always says. Ask them if they avoid things that say may contain traces or produced in a factory. It’s a long discussion but basically every allergy gives different advice and every family makes different decisions. So some people avoid it and some don’t because at least if you then have to buy food for them you have to know which foods to look out for. If you have to cook for somebody with a food allergy you don’t have to sort of like get the sanitizing agency to come and clean your house. You know it’s just good cleaning particularly with a household cleaner can get rid of any allergen if you’ve washed your dishes. Now if some folks in a washing machine or dish washing machine then that’s fine. So just clean your house and remove the allergen so that the person feels safer. If you look off the younger ones with food allergies. I would say it is highly highly important to know how to give the epinephrine and to know what symptoms of food allergy looks like. So, I’m quite active on Twitter and one of the tweets that came out yesterday is that we have to understand how young children communicate they’re having an allergic reaction. And so, some children will just start to act out of character maybe a very chatty playful kid that goes in sitting the corner go very silent all of a sudden. That’s huge change in behavior. We need to be aware of that. Sometimes they sort of like scratching their mouth and try and look like they’re trying to pull their tongue out and they say “this food itches me.” So that’s another sign they may be an allergic reaction. So, important to talk to the mom and the dad. Ask in the past when that reaction how did they present? I think you noticed it’s just being mindful that perhaps especially teenagers they don’t really want to talk about their allergies you know perhaps. They not telling you they’re coming for a sleepover and they can’t have milk and when everybody’s eating pizza, they may just say I’m not hungry or not to eat but deep down they may be absolutely panic stricken that somebody is going to be touching with the cheese. Some children are concerned to that extent or they may be concerned about all the pots of yogurt lying around. So, I do think it is. Ask them what their comfort zone looks like and try and behave within that.  

Mathea Ford [00:45:26] That’s great advice. As for thinking about the teenagers because I have a couple of teenagers. They just don’t want to be different so they don’t want to be called out to be anything different.  

Carina Venter [00:45:36] It’s interesting my daughter has a friend with an almond allergy and for her birthday they went to like something kitchen. You know where they all cook their own food. And she particularly chose this place because they’re very allergen aware. But this girl repeatedly asked her not to make an announcement about that almond allergy and not to tell everybody that she chose that place because of her allergy. And it’s that teenagers can be very very sensitive about that. And the other thing is we actually had in the 20 years I left on the Isle of Wight we had two deaths due to food allergy. But the one was a teenage boy who had a meal from a Chinese restaurant which he used to order from that chain where he lived and just north of London came to the Isle of Wight south of London thinking the ingredients would be the same. Even though the dish in the chain was the same it had some peanut in and he had his girlfriend with him. And when he felt that he starts to react he didn’t want her to see him with the hives and the swollen eyes and lips and he went to hide in the bathroom and died on the way to the hospital. So, once again you know if you have a teenager you’re working with or even a child with a food allergy and all of a sudden they just disappear and lock a door. Get in there because that perhaps just hiding because they don’t want people to see them having the reaction.  

Mathea Ford [00:47:05] All right. So, the question I always ask my guests at the end is what’s your favorite food? We’ve talked about a lot of foods. So, what is your favorite food?  

 Carina Venter [00:47:14] Oh! Spinach.  

Mathea Ford [00:47:18] How do you cook it? Or do you cook it?  

Carina Venter [00:47:21] No you know I think so. I’m South African and the way that we cook spinach is we we cook the spinach with some onion and some potato and then we mash it all up. If you want to go for the very unhealthy version you can put a lot of butter in that with a lot of salt and a lot of pepper. But in my house it would just be the spinach you know with the onion and the potato and you know a little bit of pepper. But it doesn’t mean that I don’t like the ones the way my grandparents used to cook with way too much salt and butter on top as well. But I think all over you know I just I know how awfully simple food. You know I like steak but again chose my South African heritage. I like a good quality steak as well. And it’s good for the iron too.  

Mathea Ford [00:48:12] Great! Well Carina thank you so much for being on the podcast today. It was a pleasure to have you on the show. I know my listeners learned a lot about food allergies and just kind of living with them and what’s coming next. So, if listeners want to connect with you what’s the best way to do that?  

Carina Venter [00:48:27] I am on Twitter. My name and last name the wrong way around. So, I’m @VenterCarina on Twitter because there is already another Carina Venter. And I also have my own blog Carina Ventre online they can immediately just by going on the blog or you know like my kids would say just google head you know say hey and most academics have the e-mails know on display on the Internet. You’re very welcome to e-mail me as well.  

 Mathea Ford [00:48:56] Well guys this has been another great episode of the nutrition experts podcast. The podcast that is all about learning more so you can do more with nutrition in your life. Thank you.  

 Carina Venter [00:49:07] Thank you for having me.  

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