At BFAC, we understand the unique dietary challenges patients with food related disorders are facing everyday
“Is this dish contaminated with my food trigger(s)?”
“Did the chef/server remember that I cannot eat sesame and nuts?”
“Am I getting all the nutrition I need with my restrictive diet?”
“Maybe I will skip dinner tonight, because I don't want my GI symptoms to get into the way of hanging with my friends. “
Food related disorders (FRD) are a diverse group of medical conditions caused by consumption of a specific food item or food group. Examples include IgE-mediated food allergy (such as nut allergy), celiac disease, eosinophilic esophagitis, food protein induced enterocolitis syndrome (FPIES), lactose intolerance and hypersensitivity to foods resulted from various underlying mast cell activation disorders. Many of these conditions can present with similar symptoms, and may cause confusion and questions such as:
I have a food allergy or an intolerance? Do I have a GI problem?
Should I be evaluated by a GI doctor, an allergist, or a dietitian? Or all three?
Case Studies
Case 1
“My 6 month old boy Alex has been very fuzzy and irritable for the past 2 weeks since we switched him from breast milk to cow’s milk formula. Does he have a cow’s milk allergy, lactose intolerance or something else?” After a thorough interview and evaluation, we found that Alex also has blood in his stool. We diagnosed him with cow’s milk protein allergic colitis. We explained to his parents that this type of cow’s milk allergy does not have a risk of anaphylaxis and Alex will most likely outgrow it by the age of 2. We did a baked milk* oral challenge in our office and Alex was able to consume it without any issues, liberating his diet quite a bit. His parents also met with our dietitian and were prescribed a comprehensive dietary plan to prevent nutritional deficiency. * Baked goods with milk as an ingredient, extensively heated at 325F for 10-15 minutes.”
Case 2
“My doctor told me I do not have celiac disease but I feel less bloated when I avoid gluten. Do I have gluten sensitivity? Have I been misdiagnosed?” We confirmed Sarah does not have celiac disease by negative HLA typing (a blood test) and diagnosed her with fructan intolerance (a condition in which the patient has difficulty digesting and absorbing fructan – similar to patients with lactose intolerance who cannot digest and absorb lactose). Fructan is a complex sugar found in wheat. By avoiding gluten, Sarah has been avoiding wheat and thus reducing consumption of fructan. It is therefore of no surprise she has symptom relief as a result. We told Sarah that while patients with either celiac disease or fructan intolerance can achieve symptoms improvement by avoiding wheat, only patients with celiac disease need to completely eliminate gluten (the protein component of wheat, barley and rye) because even a very small amount of cross-contamination can cause gut injury. On the other hand, consumption of fructan in patients with fructan intolerance does not cause any damage to the gut and there is no need to completely avoid fructan. She met with our dietitian and reviewed other dietary source of fructan, and how to effectively minimize its intake to reduce symptoms. By minimizing other source of fructan (garlic, onion and banana), her bloating has further improved. More importantly, she no longer has to worry about gluten cross-contamination once she learns the key differences between celiac disease and fructan intolerance.”
To help patients with food related disorders , Dr. Leung established BFAC in 2013 with the goal to treat these conditions using a multidisciplinary approach:
GI + allergy + nutrition
Having fellowship-trained in both allergy and gastroenterology subspecialties, Dr. Leung has unique knowledge and experience to evaluate patients from the perspectives of both an allergist and a gastroenterologist in the same setting. A broad range of differential diagnoses from both disciplines are considered, and tools available to both specialties can be used to narrow down and pinpoint the diagnosis. Once a diagnosis is confirmed and if the patient needs dietary treatment, our dietitian will work with the medical team to formulate an individualized plan.
For example, patients with eosinophilic esophagitis (EoE) often avoid cow’s milk and/or wheat as these are common triggers for the disease. A patient’s dietary preference (such as vegetarianism) may potentially increase the risk of nutritional deficiency. We have designed customized disease-specific laboratory panel to screen for potential micronutrient deficiency in patients on various elimination diets. We modified these panels further to factor in patients’ dietary preferences.
Given the increasing complexity of medical elimination diets and individual dietary preferences, we established the Quantitative Nutrition Treatment Center (QNTC) in 2019 to address the growing need of patients who suffer from nutritional deficiency due to restrictive dietary treatment for food related disorders. In addition to qualitative dietary recall and analysis techniques, we obtain a customized disease-specific laboratory panel, based on best available literature, to quantitatively identify potential nutrition gaps in at-risk patients.
In the example mentioned, the patient will obtain a comprehensive panel that screens for all potential micronutrients deficiency due to (1) milk-restrictive diet, (2) wheat-restrictive diet and (3) plant-based diet. This allow us to determine the exact micronutrient(s) that are deficient and precisely to what degree. A personalized diet plan can then be formulated and prescribed. Our nutrition prescription focuses on the use of natural food sources to replenish the deficiencies. Oral or IV supplements can also be given in refractory or severe cases when indicated.
Diets at a Glance
Created by: Zoe Tabakin & Yijie (Claire) Cheng
Dietetic Interns at Tufts Medical Center
Friedman School of Nutrition Science and Policy