Asthma Management Handbook

Food allergy and intolerance in asthma

Recommendations

Investigate food as a potential asthma trigger if patients report apparent links (e.g. asthma symptoms from suspected or repeated food reactions).

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If asthma symptoms appear to be triggered by intolerance to food or food additives, refer to a specialist for investigation if possible.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Explain to patients that elimination diets should only be conducted under supervision of a doctor or dietitian.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Explain to patients that food allergy is commonly accompanied by asthma-like respiratory symptoms, but that food allergy is rarely the cause of chronic asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Correct any misconceptions patients may have about foods and asthma, including:

  • dietary asthma triggers (e.g. explain that foods, and food additives other than sulphites, rarely trigger asthma symptoms)
  • the roles of dietary supplementation or restriction in asthma management.

Table. Association between food chemicals and asthma

Food chemical

Sources

Association with asthma

Benzoates (food additives 211, 213, 213, 216, 218)

Common preservative in soft drinks and foods

Probably minimal

Monosodium glutamate (food additive 621) and naturally occurring

Natural sources in fresh foods include tomatoes, various vegetables, mushrooms, fish, cheese, milk

Added as flavour enhancer

Probably minimal

Sulphites (food additives 221, 222, 223, 224, 225, 228)

Common preservative used in processed foods, dried fruits, medicines, beer, wine

May trigger acute asthma (uncommon)

 

Tartrazine (food additive 102)

Colouring

Probably minimal

Salicylates (naturally occurring)

Stone fruits, berries, dried fruits, gherkins, concentrated tomato products, curry powder, paprika, thyme, garam masala, rosemary, tea

Probably minimal risk for people with aspirin-exacerbated respiratory disease

Sources

Ardern K, Ram FSF. Tartrazine exclusion for allergic asthma. Cochrane Database Syst Rev 2001; Issue 4. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000460/full

Global Initiative for Asthma. Global strategy for asthma management and prevention (updated December 2012). GINA; 2012. Available from: http://www.ginasthma.org

New South Wales Food Authority. Monosodium glutamate (MSG). Publication number NSWFA/CE010/0703. Sydney: NSW Food Authority, 2013. Available from: http://www.foodauthority.nsw.gov.au

Zhou Y, Yang M, Dong BR. Monosodium glutamate avoidance for chronic asthma in adults and children. Cochrane Database Syst Rev 2012; Issue 6. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004357.pub4/full

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Table. Effects of dietary strategies in asthma management Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/56

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Dietary triggers

Foods are rarely a trigger for asthma.1

Food chemicals and additives

Sulphite additives (widely used as preservative and antioxidants in the food and pharmaceutical industries) have been associated with acute asthma.2

An estimated 3–10% of people with asthma are sensitised to sulphites.2

See also: Dietary salicylates

Wine

Wine has been documented to trigger asthma symptoms.3 The mechanism appears to be complex and varies between individuals.3, 4 Components of wine implicated in asthma reactions include sulphite additives and histamines.3

Although sensitivity to sulphites in wine has been demonstrated in individuals in clinical studies, this mechanism does not explain all asthmatic reactions to wine.3, 4, 5 The amount of sulphite in wine varies between brands. In general, there is more preservative in white wine than red wine, and more in cask wine than bottled wine.6

Some challenge studies suggest that antihistamines may reduce the severity of asthma symptoms due to wine.6 In general there is more histamine in red than white wines and more in Shiraz than Cabernet.6

Thermal effects

Asthma symptoms provoked by cold drinks are commonly reported anecdotally. Asthma symptoms and a reduction in FEV1 after drinking icy water have been observed in children with asthma.7 Increased bronchial hyperresponsiveness has been observed approximately 90 minutes after ingestion of ice.7

Dairy foods

Milk and other dairy foods do not increase mucus.8

Table. Association between food chemicals and asthma

Food chemical

Sources

Association with asthma

Benzoates (food additives 211, 213, 213, 216, 218)

Common preservative in soft drinks and foods

Probably minimal

Monosodium glutamate (food additive 621) and naturally occurring

Natural sources in fresh foods include tomatoes, various vegetables, mushrooms, fish, cheese, milk

Added as flavour enhancer

Probably minimal

Sulphites (food additives 221, 222, 223, 224, 225, 228)

Common preservative used in processed foods, dried fruits, medicines, beer, wine

May trigger acute asthma (uncommon)

 

Tartrazine (food additive 102)

Colouring

Probably minimal

Salicylates (naturally occurring)

Stone fruits, berries, dried fruits, gherkins, concentrated tomato products, curry powder, paprika, thyme, garam masala, rosemary, tea

Probably minimal risk for people with aspirin-exacerbated respiratory disease

Sources

Ardern K, Ram FSF. Tartrazine exclusion for allergic asthma. Cochrane Database Syst Rev 2001; Issue 4. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000460/full

Global Initiative for Asthma. Global strategy for asthma management and prevention (updated December 2012). GINA; 2012. Available from: http://www.ginasthma.org

New South Wales Food Authority. Monosodium glutamate (MSG). Publication number NSWFA/CE010/0703. Sydney: NSW Food Authority, 2013. Available from: http://www.foodauthority.nsw.gov.au

Zhou Y, Yang M, Dong BR. Monosodium glutamate avoidance for chronic asthma in adults and children. Cochrane Database Syst Rev 2012; Issue 6. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004357.pub4/full

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Dietary salicylates

Aspirin-exacerbated respiratory disease is a syndrome of airway inflammation that includes asthma, nasal polyposis, chronic rhinosinusitis, and reaction to NSAIDs. It can present with severe sudden-onset asthma. People with aspirin-exacerbated respiratory disease may react to one or more anti-inflammatory agent.

Salicylates are found in some foods (e.g. stone fruits, berries, dried fruits, gherkins, concentrated tomato products, curry powder, paprika, thyme, garam masala, rosemary, tea).9 Most foods that contain salicylates contain both salicylic acid and acetylsalicylic acid, and about one-third contain only acetylsalicylic acid.10 Dietary salicylates are generally thought not to cause symptoms in people with aspirin-exacerbated respiratory disease.11 

Salicylate elimination should only be considered under specialist supervision.

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Elimination diets

Strict dietary elimination and spirometry measurement of FEV1 after double-blind food chemical challenge is the most reliable method for detecting food chemical intolerance in people with asthma.12 Positive responses (reduction in bronchial hyperresponsiveness) to placebo challenge are common during unmodified diets.12

For people with asthma and food intolerances, elimination diets do not always improve bronchial hyperresponsiveness.13

Salicylate elimination diets are controversial.1110 Salicylate elimination diets may put children at risk of nutritional deficiencies and eating disorders.11

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References

  1. National Asthma Council Australia. Asthma and allergy. National Asthma Council Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/asthma-allergy-hp
  2. Vally H, Misso NL, Madan V. Clinical effects of sulphite additives. Clin Exp Allergy. 2009; 39: 1643-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19775253
  3. Vally H, Thompson PJ. Allergic and asthmatic reactions to alcoholic drinks. Addict Biol. 2003; 8: 3-11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12745410
  4. Vally H, Thompson PJ, Misso NL. Changes in bronchial hyperresponsiveness following high- and low-sulphite wine challenges in wine-sensitive asthmatic patients. Clin Exp Allergy. 2007; 37: 1062-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17581200
  5. Vally H, Thompson PJ. Role of sulfite additives in wine induced asthma: single dose and cumulative dose studies. Thorax. 2001; 56: 763-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1745927/
  6. Australasian Society of Clinical Immunology and Allergy (ASCIA). Alcohol allergy. ASCIA education resources patient information. ASCIA, Sydney, 2010. Available from: http://www.allergy.org.au/patients/product-allergy/alcohol-allergy
  7. Wilson NM, Dixon C, Silverman M. Increased bronchial responsiveness caused by ingestion of ice. Eur J Respir Dis. 1985; 66: 25-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3979474
  8. Australasian Society of Clinical Immunology and Allergy (ASCIA). Milk, Mucus and Cough. ASCIA education resources patient information. ASCIA, Sydney, 2010. Available from: http://www.allergy.org.au/images/pcc/ASCIAPCCMilkmucuscough_2015.pdf
  9. Swain AR, Dutton SP, Truswell AS. Salicylates in foods. J Am Diet Assoc. 1985; 85: 950-60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4019987
  10. Loblay RH, Soutter VL, Swain AR. Salicylate elimination diets in children. Med J Aust. 2013; 198: 603. Available from: https://www.mja.com.au/journal/2013/198/11/salicylate-elimination-diets-children
  11. Gray PE, Mehr S, Katelaris CH, et al. Salicylate elimination diets in children: is food restriction supported by the evidence?. Med J Aust. 2013; 198: 600-2. Available from: https://www.mja.com.au/journal/2013/198/11/salicylate-elimination-diets-children-food-restriction-supported-evidence
  12. Hodge L, Yan KY, Loblay RL. Assessment of food chemical intolerance in adult asthmatic subjects. Thorax. 1996; 51: 805-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC472547/
  13. Hodge L, Asthma and food chemical sensitivity (Abstract of research for Master of Science in Medicine, The University of Sydney). Royal Prince Alfred Hospital Allergy Unit, Sydney 1993. Available from: http://www.sswahs.nsw.gov.au/rpa/allergy/research/students/1993/linda.html