1. health and fitness
2. disease

Table 7.11.1 Vitamins and the immune system
Vitamin
Importance for the immune
system
Effect of deficiency on immune
system
Possible effects of supplementation
Retinol
carotenoids
Differentiation of epithelial cells
Development of lymphocytes
↑ Specific lymphocyte subgroups
Enhances activity of NK cells
Stimulates production of cytokines
Activates phagocytic cells
May be beneficial for individuals with
compromised immune systems
Does not stimulate immune responses
of healthy adults with adequate
intakes
In elderly, enhances NK cell activity,
but no effect on T-cell mediated
immunity
Conclusion: little value in well
nourished populations
Vitamin D
Immune system regulator (Lips,
2006)
Stimulates production of
antimicrobial peptides (including
those in epithelial cells of the
respiratory tract)
Role in production of TNF
Powerful antioxidant
? Reduces prostaglandin synthesis
? Prevents oxidation of PUFA in
cell membranes
Effects on cytokine production
↓ Physical barriers and impairs
mucosal immunity
↓ Total number of lymphocytes
↓ Lymphocyte function
Altered cytokine networks
Altered antibody responses to
antigens
Impaired antibody production
↓ Phagocytic activity of neutrophils
No alteration of neutrophil
numbers (in absence of infection)
↓ Number and activity of NK cells
Impaired growth, activation and
function of B lymphocytes
? ↑ Immune response to flu virus
? Predisposes children to
respiratory infections
↑ Susceptibility to infections due
to impaired localised innate
immunity and defects in cellular
immune response
Impairs B and T cell immunity
(Pekmezci, 2011)
↓ Lymphocyte proliferation
responses
↑ Serum IgM concentrations, but
impaired antibody production
Impaired function of phagocytes
Vitamin E
Vitamin C
Vitamin B6
Folate
Vitamin B12
Stimulant of leucocyte functions,
especially neutrophil and
monocyte movement (important
in phagocytosis and lymphocyte
functions)
Antioxidant protection at
inflammatory sites, preventing
oxidant mediated tissue dammage
? Regulation of inflammatory
response
Required for synthesis and
metabolism of amino acids, and
so for the formation of many
immune cells and substances
↑ Production of interleukins
Important in protein synthesis
Impaired lymphocyte proliferation
of T cells
Impaired inflammatory response
Impaired function of phagocytes
Interactions with folate
mechanism
Regulatory agent for cellular
immunity
Alterations in immunoglobulin
secretion and antibody response
↓ Number of lymphocytes
Suppresses NK cell activity
Modifies and impairs antibody
production
Modifies T cell activity
Lymphocyte growth and
maturation altered
Affects cell mediated immunity by
reducing proportion of circulating
T lymphocytes, leading to ↓
resistance to infections
NK, natural killer; TNF, tumour necrosis factor; PUFA, polyunsaturated fatty acid.
Manual of Dietetic Practice, Fifth Edition. Edited by Joan Gandy.
© 2014 The British Dietetic Association. Published 2014 by John Wiley & Sons, Ltd.
Companion Website: www.manualofdieteticpractice.com
↑ Subgroups of T cells in women at
low doses
? ↓ Incidence of viral respiratory
infections (Cannell et al., 2006)
Conclusion: none confirmed
? Enhances immune functions (at
doses higher than recommended
levels) in elderly people (↑ antibody
production; ↓ incidence of infections)
? Reduces exercise induced muscle
damage and that associated with
antiretroviral drugs
Conclusion: may improve immune
status, particularly in elderly, but
conflicting results on decreased
respiratory tract infections
Enhances neutrophil chemotaxis
In reponse to infection, enhances T
lymphocyte proliferation (↑ cytokine
production, ↑ synthesis of
immunoglobulins)
Conclusion: no consistent effect on
incidence of colds, but possible
modest effect in decreasing duration
and severity
Correction of deficiency rectifies
effects on the immune status
Conclusion: no additional benefit to
healthy adults
? In elderly, improves immune
function by altering age related ↓ in
NK cell activity
Conclusion: possible protection
against infections in elderly, but
conflicting results with suggested
mechanisms
Reverses deficiency effects
Conclusion: no additional benefit to
healthy adults
Table 7.11.2 Minerals, trace elements and the immune system
Mineral/trace
element
Importance for the immune
system
Effect of deficiency on immune
system
Possible effects of supplementation
Iron
(Munoz et al.,
2007)
Proliferation of lymphocytes
Part of iron metalloenzymes
involved in oxidative
processes
May favour infectious pathogens by
providing them with a supply of iron for
growth and replication (SACN, 2010)
? Effect on morbidity and mortality from
infections is uncertain
Conclusion: no evidence to suggest that in
the UK this has adverse effects on infectious
disease incidence or morbidity. Possibly
adverse effects on individuals with HIV and
children at risk of diarrhoea
Zinc
(Prasad,
2008; Prasad
et al., 2007;
Ibs & Rink,
2004)
Cofactor for substances
that modulate cytokine
release and thus essential
for highly proliferating cells
Helps to maintain skin and
mucosal membrane
integrity
Antiviral effect
Regulates activation of
acute phase response
Selenium
(Beckett et al.,
2004)
Component of
selenoproteins with some
enzymes that exert
antioxidant activity
(involved in the removal of
excess potentially damaging
radicals)
Essential for both
cellmediated and humoral
immunity
Stimulates lymphocytes and
NK cells
Interactions with vitamin E
Cofactor in copper
dependent enzymes that
are important in
antioxidant defence
(diminishes damage to
lipids, proteins and DNA)
Intracellular killing of pathogens
impaired
Slight ↓ in macrophage cytotoxicity
↓ T lymphocyte count
Absence of normal immune
response to a particular antigen or
allergen
↓ T cell function
↓ Innate immune response
Altered balance between pro- and
anti-inflammatory cytokines
↓ B and T lymphocyte proliferation
and imbalance in T cell
subpopulations
Defects in cell mediated immunity
demonstrated by a depression in
delayed hypersensitivity responses
↑ Susceptibility to infections
↓ Number of mature T cells and ↑
in immature T cells
Damages protective barrier of the
skin, respiratory and gut linings
and impaired wound healing
Impairs innate immunity (impaired
chemotaxis by neutrophils and
macrophages, ↓ NK cell activity)
Compromises neutrophil
chemotaxis and macrophage
function and subsequent killing of
phagocytosed bacteria
↑ Oxidative damage in immune cell
membranes
↓ Resistance to viruses
Impaired antibody production
? ↑ Risk of developing some
cancers
↓ Number of circulating neutrophils
Affects synthesis and secretion of
cytokines
In animals, impairments in immune
function (↓ thymus weight, ↓
production of antibodies, ↓ activity
of NK cells, ↓ antimicrobial activity
of phagocytes)
↑ Thymus cell proliferation
↑ Levels of interleukins and TNF
↓ Levels acute phase proteins and
complement
Influences cytotoxicity of T cells and
functioning of adhesion molecules
↓ Lymphocyte antioxidant enzyme
activity
In animals, ↓antibody synthesis and
secretion
? Correction of deficiency rectifies effects on
the immune status (phagocytic index
returns to normal values)
? Immunosuppressive at high levels
Conclusion: further clinical trials needed.
Copper
Magnesium
Component of enzymes
and needed for normal
functioning
Manganese
Component of enzymes
and needed for normal
functioning
Antioxidant activity
NK, natural killer; TNF, tumour necrosis factor.
↑ Cellular components of innate immunity,
antibody responses and number of cytotoxic
cells
↓ Induced apoptosis of macrophages and T
cells
Reversal of T cell reduced responses when
deficiency corrected
High levels cause impairment in immunity
(in phagocytic cell and lymphocyte function)
Conclusion: zinc has a major role in the
immune system at all levels and deficiency
manifests with increased susceptibility to
infectious agents. Zinc supplementation may
help reduce the incidence of infections,
especially in the elderly
↑ Cytotoxic action against virus infected
cells
Eradication of Keshan disease
Improved immune system function
Conclusion: correction of deficiency rectifies
effects on the immune status. Possible role
in cancer prevention and therapeutic effect
on some inflammatory diseases
Conflicting results on improvement of
asthma symptoms
Conclusion: additional studies warranted
?Antibody production improved, but only to
certain level (in large amounts inhibition of
production occurs)
Can cause secondary iron deficiency leading
to iron deficiency induced immune system
abnormalities
Conclusion: none confirmed
Table 7.11.3 Summary of nutrient requirements for the functioning of the immune system (Maggini et al., 2007)
Body’s defence system
Nutrients required
Skin barrier function
Vitamins A, C and E
Zinc
Vitamins A, B6, B12, C,
D and E
Folic acid
Iron
Zinc
Copper
Selenium
Manganese
Magnesium
PUFA
Methionine
Cysteine
Synergistic working to support
protective activities in immune cells
(cellular immunity)
Antibody production
B cell proliferation
Promotion of humoral immunity
Indirect action on protein synthesis
and/or cell growth
PUFA, polyunsaturated fatty acid.
Vitamin B6
Selenium
Copper
Zinc
Glutamine
Vitamins A, D and E
Arginine
Vitamin B12
Folic acid
Magnesium
Manganese
Table
7.11.4 Symptoms
hypersensitivity
experienced
with
food
Target organ
Symptoms
Skin
Pallor
Erythema
Pruritus
Urticaria
Angio-oedema
Eczema
Dermatitis herpetiformis
Oral allergy syndrome
Food protein enteropathy syndrome
Gastro-oesophageal reflux
Allergic eosinophilic gastroenteritis/
oesophagitis
Oral itch, throat itch, lip swelling
Diarrhoea, nausea, vomiting
Abdominal pain
Enteropathy
Proctocolitis
Enterocolitis
Coeliac disease
Constipation
Heiner’s syndrome
Rhinorrhoea
Asthma
Hypotension
Anaphylaxis
Exercised induced anaphylaxis
Otitis media
Hyperactivity
Migraine/abdominal migraine
Enuresis
Irritability
Listless with other symptoms
Gastrointestinal tract
Respiratory tract
Multisystem
Controversial
symptoms
Other
Table 7.11.5 Allergy prevention advice
Who is at risk?
Breastfeeding
recommendations
Alternatives if
breastfeeding not
possible or insufficient
AAP position statement
ESPACI/ESPGHAN (1999)
EAACI (2008)
If both parents or parent and
sibling have documented
allergic disease
Exclusive breastfeeding up to
6 months
Use an eHF, but a pHF could
be considered
If have one affected parent or
one affected sibling
If have one first degree relative with
documented allergic disease
Exclusive breastfeeding 4–6
months
Use formula with proven
reduced allergenicity
Exclusive breastfeeding, preferably for
6 months but for at least 4 months
Use an eHF until 4 months of age. A
pHF may have an effect, although it
seems to be less effective than eHF
AAP, American Academy of Pediatrics; ESPACI, European Society of Pediatric Allergology and Clinical Immunology; ESPGHAN, European
Society for Pediatric Gastroenterology, Hepatology and Nutrition; EAACI, European Academy of Allergology and Clinical Immunology;
eHF, extensively hydrolysed formula; pHF, partially hydrolysed formula.
Table 7.11.6 Less restrictive few foods diet (Vikerstaff Joneja, 1998)
Meat and alternatives
Acceptable grains and flours
Lamb
Turkey
Chicken
Potato flour, rice flour, cornflour,
arrowroot, sago, tapioca, millet, buckwheat
Starchy foods
Rice (white), pudding rice, rice noodles, rice cakes – plain, Rice
Krispies
Cornflour, corn flakes, maize flour, polenta – (not sweetcorn)
Potatoes (no skin) – cooked in any way as long as permitted
margarines or oils are used in their preparation
‘Kettles’ potato chips, only lightly salted flavour
Oven chips or micro chips with no preservatives added
Baking aids
Cream of tartar, sodium bicarbonate, pectin
Fruit
Pears
Nectarines
Peaches
Mango
Fruit should be washed thoroughly and peeled before it is
eaten
Tinned fruit in syrup or fruit sorbet made from the allowed
fruit is acceptable, but make sure that no preservatives or
colourings have been added
Adding extra calories to food
Sugar, golden syrup
Vegetables
Carrots
Parsnip
Greens – only broccoli, marrows and courgettes
Swede
French beans
Squash
Sweet potatoes
No other foods are allowed at all
This includes sweets, chewing gum, popcorn or corn snacks, fizzy
drinks or squashes (and alcoholic drinks)
This also means no milk or any dairy products.
No vinegar or bottled sauces are allowed
Milk substitutes
Suitable gluten and wheat free products that may be
purchased from your pharmacy
Ener-G Rice loaf
Ener-G Rice pasta
Glutano Gluten free pasta
Glutano Crispbread
Trufree Cake mix
Trufree Pastry mix
Dr. Schar Mix A – Cake mix
Dr. Schar Mix C – Flour mix for cooking
Rice milk with added calcium
Fats and oils
Margarine made from vegetable oil, e.g. Pure, Granose
vegetable margarine, Vitaquelle or Vitaseig
Supermarket’s own brand of milk free/soya free margarines.
Soya margarines are not allowed
Any oil, e.g. sunflower, olive, rape seed, vegetable, will be
suitable.
Flavourings
Sea salt and pepper in moderation
Herbs – mint, parsley, sage, thyme, basil, oregano, rosemary
We do not recommend using a lot of herbs, just a little bit of
your favourites
Drinks
7-Up (non diet) limit to 1–2 cans/day
Water (filtered if possible)
Juices from allowed fruit but make sure that they do not
contain any colourings or preservatives
*
Basic instructions
• You will have started by following the observation phase for 7
days, recording foods and drinks normally taken and symptoms
experienced on your normal diet.
• During the observation phase you will have time to plan and
shop ahead. It will be necessary to have plenty of appropriate
foods to hand.
• The menu is simple – without spices, butter or condiments.
• Do not start at Christmas or around birthdays.
• Use as many fresh food sources as possible.
• Frozen food is the next best alternative.
• You may initially feel worse, but your symptoms should
improve within 3–4 days.
This diet should always be followed under the supervision
of your dietitian
Foods will be reintroduced one at a time after a * day period
Please do not hesitate to contact the dietitian on: *
Number of days and contact details to be supplied by local practitioners.
Table 7.11.7 Subjective and objective symptoms during food challenge (Niggemann, 2010)
Possible problems with interpretation
Subjective symptoms
Nausea
Stinging/burning of tongue or mouth
Itching
Heart palpitations
Sleeplessness
Irritability
Excitement
General change of behaviour/sense
of impending doom
Diarrhoea
Abdominal pain and cramps
Objective symptoms
Flushing
Urticaria
Slight worsening of eczema
Vomiting
Cardiovascular symptoms – especially
a drop in blood pressure
Respiratory symptoms
Dyspnoea/difficulty breathing
All difficult to interpret due to the subjective nature of the symptoms
Highly predictive of a positive challenge
Could be caused by stress
Could be caused by stress, but also a sign of impending anaphylaxis
Difficult to interpret if subsides very quickly
Could be contact urticaria if only around the mouth
Generalised urticaria (in the absence of chronic urticaria) is almost always a sign of a
positive challenge
Difficult to interpret/could be contact related
However, scored index increase of >15 points is very indicative of positive reactions – may
need to wait 48 hours for assessment
Could be caused by food aversion – may need to ensure that vomiting occurs more than
once and is severe in nature for a positive result
Almost always a sign of a positive challenge
Could be aero allergen related/generally uncontrolled symptoms
However, stridor, wheeze, watery rhinitis, redness of eyes and nose, and tears are almost
always signs of a positive reaction
Could be aero allergen related but is often a sign of a positive challenge
Table 7.11.8 Criteria for major and minor criteria for outcome
of challenge
Major criteria
Minor criteria
≥3 hives
≥1 site of angio-oedema
Wheezing
Dyspnoea
Stridor
Dysphonia
Aphonia
Severe persistent abdominal
symptoms for ≥30 minutes,
e.g. abdominal pain/stillness,
vomiting, nausea or diarrhoea
Hypotension for age
Eczematous pruritic rash
(worsening to ≥10 SCORAD
points)*
1–2 hives
≥1 of sneezing, congestion
or rhinorrhoea
Conjunctivitis
≥1 of nausea, vomiting or
diarrhoea for <20 minutes
A change in behaviour, e.g.
irritability, drowsiness,
decreased activity, anxiety,
distress
• Positive food challenge: presence of ≥1 major criteria or ≥2
minor criteria.
• Negative food challenge: absence of a major or minor
criteria.
*Worsening of eczema alone is not a stopping criterion during
the challenge. However, if a worsening of eczema to >10
SCORAD points is observed at the end of the active arm of the
double blind placebo controlled food challenges (DBPCFC) with
no worsening of eczema with the placebo challenge, the diagnosis of cow’s milk allergy will be given.
Table 7.11.9 Nutritionally complete milk substitutes for use in cow’s milk hypersensitivity
Type of milk hypersensitivity
Product type*
Product name (manufacturer)
Used for IgE and non-IgE
mediated cow’s milk allergy
Soya based**
Do not use before 6 months unless
no other choice, e.g. vegan or refusal
of all other suitable formula
Casein based hydrolysed cow’s milk
Infasoy (Cow & Gate)
Wysoy (SMA)
Lactose intolerance only
Nutramigen Lipil 1 and 2 (MJN)
Pregestimil (with MCT oils) (MJN)
Whey based hydrolysed cow’s milk
Pepti Junior (Cow & Gate)
Pepti 1 and 2 (Aptamil)
Amino acid
Neocate LCP (SHS)
Neocate Advance and Neocate Active if over 12 months (SHS)
Nutramigen AA (MJN)
NB: Some of the above products may also be suitable for lactose intolerance; check prescribing
indications
Usually contain whole cow’s milk
Enfamil Lactofree (MJN)
protein
SMA LF (SMA)
*The choice of product depends on the age of the child, the level of sensitivity to milk and the presence of coexisting allergies. Check
compositional details and prescribing indications for suitability. Choice may also be dictated by the infant’s palate.
**Infants under the age of 6 months should not use a soya formula as the first choice due to their phyto-oestrogen content and the
risk of becoming sensitised to soya. It can be used if other formulae are either not suitable, not acceptable or not tolerated by the
infant, or if the mother is vegan. See www.bda.uk.com for the BDA Paediatric Group Position Statement on the use of soya protein
for Infants.
Further details of products currently available and their prescribing indications can be found in the British National Formulary (BNF) or
the Monthly Index of Medical Specialities (MIMS) or obtained directly from the manufacturers. Further information is also available to
dietitians in the Special Foods for Children booklet compiled by the Dietetic Department, Children’s Hospital, Birmingham.
MCT, medium chain triglyceride.
Table 7.11.10 General guidance for milk exclusion
Exclude
Examples of foods to exclude
Notes
Cow’s milk
Liquid whole, semi skimmed or skimmed milk
Evaporated or condensed milk
Dried full fat or skimmed milk powder
Fresh and UHT
Dairy products
Butter
Margarine or fat spreads containing milk derivatives
Cheese and cheese spreads
Yogurt
Fromage frais
Creme fraiche
Cream
Ice cream
May be described on ingredients lists as: milk, milk solids,
non-fat milk solids, milk protein; skimmed milk, skimmed milk
powder
Casein or caseinates
Whey; whey solids; buttermilk
*Lactose, milk sugar, whey sugar, whey syrup sweetener. Within
the European Union the presence of milk must be clearly labelled
Goat’s, sheep’s and other mammalian milk
should not be used as an alternative to
cow’s milk. They are also unsuitable for
people requiring total exclusion of lactose
or galactose
Butter and some hard cheeses may be
tolerated by people with mild lactose
intolerance
Milk or milk
derivatives in
manufactured
foods
Lactose in flavourings and medications
may be a problem in some severely allergic
patients
*It may not be necessary to exclude lactose and other milk sugars in all cases of cow’s milk allergy but, for practical purposes, their
presence is usually taken as indicative of the presence of milk, and foods containing them are excluded.
Table 7.11.11 Types of manufactured foods that may contain
milk or milk derivatives
Food type
Foods to check
Cereals
Bread and rolls
Breakfast cereals
Cakes
Biscuits and crackers
Pizza
Pasta (both fresh and tinned)
Vegetables canned in sauce
Instant potato
Baked beans
Battered or breadcrumbed vegetables
and potato products
Meat and fish products, e.g. beef
burgers, fish fingers, sausages, ready
meals
Canned and packet soups
Instant gravies
Sauces/ketchups
Crisps and savoury snack foods
Instant desserts
Dairy desserts
Ice cream
Custards
Chocolate
Toffee
Fudge
Caramel
Margarines and fat spreads
Instant drinking chocolate
Malted milk drinks
Coffee whiteners
Pineapple and coconut juice drink
Fruit and
vegetables
Meat, fish and
alternatives
Other savoury
items
Desserts
Confectionery
Fats and spreads
Beverages
NB: This list is far from exhaustive and all food labels must be
checked carefully and checked every time as ingredients do
change.
Most of these products can also be milk free if you shop around
or use ‘free from lists’ to locate them.
Table 7.11.12 Guidance for peanut and tree nut avoidance
Exclude
Examples
Notes
Peanuts and tree
nuts
Peanut
Brazil
Walnut
Hazelnut
Almond
Cashew
Pistachio
Pecans
Macadamia
Peanut butter and other nut spreads
Praline
Noisette
Marzipan
Frangipan
Amaretto products
Macaroons
Bakewell tarts
Almond essence
Marron, e.g. marron glacé
Some of these may be described as:
Mixed nuts
Ground nuts
Monkey nuts
Earth nuts
Goober nuts
Nutmeg, coconut, pine nut and palm nut are not classified as
nuts
Worcester sauce
Satay sauce
Korma sauce
Pesto sauce
Hydrolysed vegetable protein
Contains walnuts
Contains peanuts
Contains almonds and sometimes peanut paste
Made from pine nuts, but could contain other nuts
Usually from soya or wheat but can be derived from peanut, but
this should be labelled clearly on prepacked manufactured foods
in the European Union
Nut cheeses sold on deli counters can contaminate other products
Refined oils present in manufactured foods or sold as cooking oils
are free from nut protein but still have to be declared on food
labels
Spreads
Sweets
Desserts and
dessert topping
Sweet paste or ice
cream
Sauces
Hydrolysed
vegetable protein
Cheese
Oils
Manufactured
foods containing
traces of peanuts
or nuts
Nut containing or nut coated cheeses
Cold pressed gourmet oils, also called
unrefined oils
Peanut oil
Arachis oil
Groundnut oil
Walnut oil
Almond oil
Hazelnut oil
This can include almost any food but
particularly:
Cakes, biscuits and pastries
Ice cream, desserts and dessert
toppings
Chocolate bars
Cereal bars and confectionery
Savoury snack foods
Breakfast cereals, especially muesli or
nut mixtures
Products containing hydrolysed
vegetable protein
Oriental/Asian food
Sauces and salad dressings
Mixed salads
Wild rice
Almond paste used in curries often contains peanuts
Usually made from hazelnuts but mixed nuts can be used
Contain almonds but cheaper brands may contain peanut flour as
an extender
Made from chestnuts but other nuts may be included
All manufactured foods should be considered a source of
peanuts/nuts until it is known that this is not the case
Table 7.11.13 Soya containing foods (L’Hocine & Boye, 2007)
Whole bean
products
Hull products
Protein
products
Oil products
Emerging
products
Soya sprouts, edamame, soya milk, tofu,
miso, natto, yuba, tempeh, soya sauce,
soya nuts, soyanut butter, soya cereals,
soya cheese, soya milk, soya ice cream/
yoghurt/desserts
Bread, bakery products, snack bars
Soya flour, protein concentrate, protein
isolate, textured soya
Baby foods, infant formulae, bread,
biscuits, pancakes, pastry, crackers, snack
foods, noodles, pizza, breakfast cereals,
soya milk, ice cream, soya yoghurt and
cheese, sausages, tinned meat and fish,
soups and gravy, beef burgers, salad
dressing, stock cubes, sauces
Refined oil, lecithin
Cooking oil, salad oil, margarine, salad
dressing, mayonnaise, coffee whiteners,
chocolate, sweets, pastry filling, cheese
dips, emulsifying agents, dietary
supplements and body building agents
Isoflavones, functional foods, medications
Table 7.11.14 Sesame products
Alternative names
Foods containing sesame
Ajonjoli
Benne/benne seed
Gomasio
Gingelly
Sesamum indicum
Sim sim
Oleum
Teel
Till
Falafel
Burger buns
Bread sticks
Pastries
Pretzels
Bagels
Biscuits
Rice cakes
Crackers
Sandwiches
Halva
Hummus
Tahini
Salad dressing
Soups
Sauces
Noodles
Samosa
Dips
Aqua Libra
Table 7.11.15 Classification of egg containing foods
Well cooked egg
Lightly cooked egg
Raw egg
Cakes
Biscuits
Dried egg pasta
Pancakes and Yorkshire pudding
Egg in sausages, both vegetarian
and meat varieties, and also in
other processed meats such as
burgers
Prepared meat dishes
Well cooked fresh egg pasta
Quorn
Sponges and sponge fingers
Chocolate bars that contain
nougat or dried egg, e.g. Milky
Way, Mars bar or Creme egg
Some soft centred chocolates
Soft fruit chews
Egg in some gravy granules
Dried egg noodles
Waffles
Commercial marzipan
Scrambled egg
Boiled egg
Fried egg
Omelette
Egg fried rice
Meringues
Some marshmallows
Lemon curd
Quiche
Poached egg
Pancakes
Egg in batter
Egg in breadcrumbs, e.g. on fish fingers and chicken nuggets
Hollandaise sauce
Quiche and flans (fruity and savoury)
Egg custard and egg custard tarts
Crème caramel
Crème brulée
Real (egg) custard
Tempura batter
Yorkshire pudding – some patients who can eat well cooked
egg can tolerate this, but it depends on how well cooked
they are and if they contain any uncooked batter inside
Fresh mayonnaise
Fresh mousse and shop
bought mousse that contains
egg
Fresh ice cream
Sorbet
Royal icing (both fresh and
powdered icing sugar)
Home made marzipan
Raw egg in cake mix and other
dishes awaiting cooking
(children of all ages love to
taste or lick the spoon!)
Egg glaze on pastry
Horseradish sauce
Tartar sauce
Cheese containing egg white
in the form of lysozyme
Mayonnaise
Salad cream
Table 7.11.16 Cross reacting plant food allergens
Birch pollen
Birch/mugwort
Grass
Ragweed
Plane tree
Latex
Apple, pear, cherry, peach, nectarine,
apricot, plum, kiwi, hazelnut, other nuts,
almond, celery, carrot, potato
Celery, carrot, spices, sunflower seed,
honey
Melon, watermelon, orange, tomato,
potato, peanut, Swiss chard
Watermelon and other melons, banana,
courgette, cucumber
Hazelnut, peach, apple, melon, kiwi,
peanuts, maize, chickpea, lettuce, green
beans
Avocado pear, chestnut, banana, passion
fruit, kiwi fruit, papaya, mango, tomato,
pepper, potato, celery
Table 7.11.17 Dietary guidance for wheat exclusion
Cereal foods that must be excluded
Other foods that may
need to be excluded
Cereal foods that can
be included
All types of bread, including rolls, malt bread, chapatti, pitta, naan, paratha,
croissants, soda bread and fancy breads
Some gluten free breads
Breakfast cereals unless derived solely from oat, rice and/or maize (corn)
Cakes, biscuits and crackers
Flour and all foods containing wheat, e.g. pastry, pies, batters, pancakes, sauces
Bran
Pasta
Semolina, couscous
Pizza
Proprietary gluten free foods containing wheat starch
Whole wheat or wheat grains
Wheat flour
Wheat starch (or modified starch)
Wheat bran
Wheat germ
Wheat binder
Wheat gluten
Wheat thickener
Cereal filler
Rusk
Breadcrumbs or bread
Manufactured foods
containing any of the
following ingredients:
Modified starch
(mostly from maize
derived)
Wheat germ oil
Wheat thickener
Raising agent
containing wheat
starch
Hydrolysed wheat
protein
Spelt
Oats*
Rye*
Barley*
Triticale*
Rice and rice flour
Corn (maize) and
cornflour (polenta)
Millet
Arrowroot
Buckwheat
Sago and sago flour
Tapioca
Quinoa
Proprietary gluten free,
wheat free foods
(NB: only prescribable
for coeliac disease,
not wheat intolerance
per se)
*Some patients may have a cross sensitisation with these grains.
Table 7.11.18 Ethnicity of HIV infected individuals seen for
care in the UK
Ethnicity
2000
2009
White
Black Caribbean
Black African
Asian/Oriental
Other/mixed
66.5%
2.5%
23.3%
2.4%
6.4%
52.0%
3.0%
36.2%
3.0%
5.9%
Table 7.11.19 CDC classification system for HIV infected
adults and adolescents
CD4 cell
category
≥500
cells/μL
200–499
cells/μL
<200
cells/μL
Clinical category
A
Asymptomatic,
acute HIV or
PGL
B*
Symptomatic
conditions,
not A or C
C#
AIDS indicator
conditions
A1
B1
C1
A2
B2
C2
A3
B3
C3
Patients in shadedd categories are considered to have AIDS.
PGL persistent generalised lymphadenopathy; CDC, USA Centers
for Disease Control.
Table 7.11.20 Recommendations for when to initiate therapy
Presentation
When to treat
Primary HIV infection
Treatment in clinical trial
Or when there is neurological
involvement
Or when CD4 <200 cells/mL for
>3 months
Or AIDS defining illness
Established HIV
infection
CD4 <200 cells/mL
CD4 201–350 cells/mL
CD4 351–500 cells/mL
CD4 >500 cells/mL
AIDS diagnosis
Treat
Treat as soon as possible when
patient ready
Treat in specific situations
with higher risk of clinical
events – see text
Consider enrolment into ‘when
to start’ trial
Treat (except for tuberculosis
when CD4 >350 cells/mL)
Table 7.11.21 Anthropometric and related assessments of individuals with HIV infection
Measurements
Anthropometric
Weight
Body mass index
Waist circumference
Mid upper arm circumference
Triceps skinfold
Mid arm muscle circumference
Hip circumference
Waist to hip ratio
Other skinfold measurements
Other measurements
Bioelectrical impedance analysis
Handgrip strength
Indication of
Overall nutritional status; however, must be interpreted in individuals with caution and with a
view to evaluating other aspects of body composition
Good marker of nutritional status in populations; can determine if overweight, obese or
underweight; interpret with caution in individuals
A good correlate of visceral fat and an indicator of metabolic syndrome
Reflection of muscle and subcutaneous fat stores; can compare with reference values and
evaluate changes over time
Subcutaneous fat stores; can compare against reference values and serial changes in an
individual
A good marker of lean body mass; useful in assessing changes in individuals
On its own can reflect buttock muscle and fat stores and can be monitored serially in
individuals
Use with reference values, but interpret in light of potential fat loss from lipoatrophy
Can be used to assess overall subcutaneous fat and estimate total body fat percentage
Low phase angles have been shown to be of prognostic relevance in HIV infected patients (Kyle
et al., 2004); however, are not sensitive to detect changes in body shape, nor should be used
to evaluate fat atrophy (Schwenk et al., 2001). Can measure body cell mass, which is a
component of some definitions of HIV related wasting (see Table 7.11.23)
A measure of muscle strength; correlates well with nutritional status; however interpret with
caution as limited reference values, and consider factors such as mood, mobility and peripheral
neuropathy
Table 7.11.22 Laboratory markers used in patients with hiv infection
Use to assess
Plasma markers
Urea
Creatinine
Potassium
Phosphate
Liver function tests (LFTs)
CD4 T cell count
Viral load
Albumin
Vitamin B12, folate
Ferritin transferrin
saturation, total iron
binding capacity, etc.
Zinc, selenium
Calcium
Vitamin D, parathyroid
hormone (PTH)
Other fat soluble
vitamins
Hormones: testosterone,
oestradiol, thyroid
Fasting lipids (total
cholesterol, HDL, LDL,
triglycerides)
Fasting glucose
Urine markers
Protein : creatinine
Fractional excretion of
phosphate (FePi)
Faecal markers
1-alpha antitrypsin
Pancreatic elastase
Hydration status, renal function (usually measured in an inpatient setting)
Renal function (also useful to calculate estimated glomerular filtration rate) (Labarga et al., 2010))
Can be low in poor nutritional states and high in chronic renal disease
Measure of phosphate intake; however, hypophosphataemia is very common in people with HIV
infection (Assadi, 2010) and needs to be interpreted in view of dietary intake, malabsorption, vitamin D
deficiency and, importantly, tubular renal losses most commonly due to antiretroviral therapy and
hyperparathyroidism. A fractional excretion of phosphate will help to determine the cause of
hypophosphataemia
Increased LFTs can be an indicator of liver function, especially considering the high prevalence of
coinfection with hepatitis B and C; however, if only alkaline phosphatase is raised, it may be due to
increased bone turnover and/or vitamin D deficiency
See text
See text
Indicator of visceral protein status and related to inflammatory states, e.g. difficult to assess in cases of
liver disease and acute infection. It is also an indicator of disease state and mortality. Can be low in
malabsorption and states of protein loss
Low in macrocytic anaemia, can be related to low dietary intakes or other causes
Low in microcytic anaemic, can be related to low dietary intakes or other causes
Need to be interpreted with caution in inflammatory states (see Micronutrients section)
Plasma levels are bound to plasma proteins (such as albumin) and are tightly regulated, so are not a
good reflector of dietary calcium intake
Vitamin D deficiency is common in HIV as it is in many other individuals. Vitamin D deficiency or dietary
calcium deficiency can result in secondary hyperparathyroidism
Can be useful to measure in patients with fat malabsorption
Measured to rule out secondary causes of wasting and low bone mineral density
Use local reference values and national guidelines for target levels
Increased fasting or random glucose should warrant an oral glucose tolerance test to rule out diabetes,
impaired glucose tolerance or impaired fasting glucose. It has been suggested that fasting insulin and
glucose should be routinely measured, and HOMA-IR calculated, particularly in those at highest risk,
such as those with metabolic syndrome, obesity, lipodystrophy or a longer exposure to antiretrovirals
(Gianotti et al., 2011).
Reflects renal protein loss and is more sensitive than a dipstick test. Should be measured annually in all
patients on ART
FePi = (urine phosphate × serum creatinine × 100)/(serum phosphate × urine creatinine). This should be
done fasting and can be used to determine whether hypophosphataemia is a result of renal losses or
inadequate dietary intake/reduced gastrointestinal absorption
A protein synthesised in the liver that is neither actively secreted nor absorbed. Use with serum levels to
determine clearance in order to help diagnose protein losing enteropathy if indicated (Umar & DiBaise,
2010)
Used to determine exocrine pancreatic function that may result in fat malabsorption and diarrhoea
Table 7.11.23 Dietetic interventions and outcomes for treating nutritional problems in patients with HIV infection
Patients requiring a dietetic referral
Dietetic interventions and outcomes of referral
All patients with HIV
Healthy eating principles that ensure adequate nutrition and promote a healthy immune
system to reduce infections and prevent development of metabolic comorbidities
Food and water safety counselling to reduce the risk of developing food and water borne
illnesses
Antenatal and postnatal nutrition and breastfeeding education (see Chapter 3.8.2)
Improving micronutrient deficiency (including iron) and constipation
Nutrition strategies for symptom management, e.g. anorexia, early satiety, swallowing
problems, thrush, nausea and vomiting, diarrhoea, food intolerances
Outcomes may be improved diarrhoea and improved dietary intake ensuring adequacy of
macro- and micro-nutrients (prevention of weight loss and loss of lean body mass, which is
known to increase mortality)
Identifying food–medication interactions and strategies to ensure optimal medication efficacy
and provide adherence support
Immunocompromised (e.g. CD4+
cell count <200 cells/mL)
Pregnant women
Poor dietary intake due to disease
or side effects of treatment
Patients taking antiretrovirals or
other medications relating to
opportunistic infections or
comorbidities
Loss of >5% of usual weight
Dyslipidaemia and/or lipodystrophy
and/or obesity and/or diabetes
and/or insulin resistance
Bone disease (osteoporosis,
osteopaenia, osteomalacia)
Allergies/intolerances or patients
following special diets/taking
excess supplementation
Patients requiring weight loss or
gain of lean body tissue
Alteration in bowel habit
Alternative feeding methods, e.g. oral supplementation, tube feeding and parenteral nutrition
Outcomes may be reduced risk of infections, mortality, hospital admissions (if an outpatient)
and length of stay (if inpatient), and improve patient experience (quality of life and energy
levels)
Strategies for treatment of body fat changes and altered metabolism (in collaboration with
the clinician) include exercise, lipidlowering medications, dietary modifications, glycaemic
control, hormonal normalisation and anabolic medications
Outcomes may be prevention of cardiovascular disease events, reduced hospital admissions
and improved quality of life (obesity related)
Assessment of dietary and lifestyle factors influencing bone mineral density (dietary protein,
calcium, phosphorus and vitamin D; exercise, risk of falls, smoking, alcohol) and advice on
altering these as needed
Advising on vitamin D ± calcium supplementation
Outcomes may include prevention of falls, fractures and hospital admissions
Evaluation of nutrition information, special diets, vitamin or mineral or other dietary
supplementation, and other nutrition practices
Prevention of toxic effects of hypervitaminosis, improved patient experience/wellbeing;
ensuring nutritional adequacy, prevention of interactions with ART or other medications
Additional activities and therapies that support good nutrition, e.g. physical exercise,
medications for symptom management, chronic disease management, etc., including referral
to appropriate exercise facilities
See outcomes for dyslipidaemia
Assessment of impact on quality of life and diet, dietary advice to improve symptoms
(constipation/diarrhoea), discussion with patient about lifestyle factors;.liaising with specialist
gastroenterology team/dietitian, communication with GP if supplements or medicines are
required
Outcomes may be improved quality of life, prevention of nutritional deficiencies and
enhanced medication absorption
ART, antiretroviral therapy.
Table 7.11.24 Definitions of HIV related wasting
CDC (Centers for Disease Control,
1987)
Consensus panel (Wanke et al., 2004)
NFHL (Wanke et al., 2000)
Involuntary weight loss of >10%
of baseline body weight + either
chronic diarrhoea or chronic
weakness and documented fever
in the absence of concurrent
illness or condition
10% unintentional weight loss over 12 months
Or 7.5% unintentional weight loss over 6 months
Or 5% unintentional weight loss over 3 months
Or in men: BCM <35% of total BW with BMI <27 kg/m2
Or in women: BCM <23% of total BW with BMI <27 kg/m2
In either men or women, regardless of BCM: BMI <20 kg/m2
Unintentional loss of >10% of
body weight
Or BMI <20 kg/m2
Or Unintentional loss of >5% of
body weight in 6 months and
persisting for at least 1 year
BW, body weight; BMI, body mass index; BCM, body cell mass.
Table 7.11.25 Observational studies of micronutrient deficiencies in relation to HIV disease
Micronutrient
Observational findings in HIV
Vitamin A
Low vitamin A levels have been associated with quicker progression of HIV disease and mortality in adults (Semba
et al., 1995, Tang et al., 1993)
Low vitamin D has been associated with HIV disease progression (Viard et al., 2011; Mehta et al., 2010). In the
general population, vitamin D deficiency has been associated with cardiovascular disease, diabetes, immune
functioning and mortality (Melamed et al., 2008)
Serum zinc levels have been linked to HIV disease progression, decreased CD4+ cell counts, and increased mortality
(Baum et al., 1997; 2003). An association was seen between people who took over the counter zinc supplements
and a more rapid progression to AIDS and mortality (Tang et al., 1993; 1996). This may be because adults with
more advanced or symptomatic HIV disease are more likely to take more supplements (Bormann et al., 2009)
Low levels have been linked with progression of HIV disease (Baum et al., 1997)
Several studies have found that a high percentage of HIV infected individuals have inadequate dietary calcium
intake (Arpadi et al., 2009; Bonjoch et al., 2010; Jacobson et al., 2008). An increased dietary calcium intake has
been associated with greater bone mineral density in HIV (McComsey et al., 2007)
Iron deficiency is common, especially in women and in developing countries, and dietary iron appears to be a
contributing factor (Castro & Goldani, 2009; Shet et al., 2012)
Hypophosphataemia is commonly seen in patients with HIV regardless of ART use (Day et al., 2005). It is thought
that use of tenofovir contributes to renal tubular losses of phosphate; however, vitamin D deficiency,
malabsorption and use of antacids can also be contributing factors (Assadi, 2010).
Vitamin D
Zinc
Selenium
Calcium
Iron
Phosphate
ART, antiretroviral therapy.
Table 7.11.26 Interventional studies of micronutrients in people living with HIV/AIDS
Micronutrient
Findings from randomised controlled trials (RCTs)
Vitamin A
No trials reviewed (Irlam et al., 2010) showed a reduction in disease progression in adults with vitamin A
supplementation. In children, vitamin A supplementation showed a reduction in mortality and moderate evidence
for morbidity and growth benefits
Limited RCTs have been done in adults or children. The doses used in trials thus far have been inadequate to
achieve optimal repletion of vitamin D stores. One trial found that vitamin D3 supplementation decreased the risk
of developing diabetes (Guaraldi et al., 2011). No risks have been seen to date (Wejse et al., 2009, Arpadi et al.,
2009)
No benefit of zinc supplements have been seen in pregnant women, furthermore, zinc inhibits iron absorption so
mitigates increases in haemoglobin levels, which are often low in pregnancy. In drug users in Florida, those who
took the dietary reference intake (DRI) of zinc as a supplement, had a decrease in immunological failure (defined
as CD4+ <200 cells/mm3) and less diarrhoea, compared to those taking placebo (Baum et al., 2010). In children,
supplementation reduced risk and progression of diarrhoea in several studies (in Africa), but not prophylactically
(Irlam et al., 2010)
Reduced diarrhoeal morbidity in pregnant women in Tanzania, and reduced viral load in two separate small trials
in American adults (with high drop out rates) (Irlam et al., 2010)
Calcium with vitamin D supplements have been given in the control arm of several trials investigating the role of
bisphosphonates in treating osteoporosis. These studies found that there was a trend for bone mineral density
increases, albeit non-significantly, in those receiving calcium supplements only; however, this was significantly less
than in those on bisphosphonates (Mondy et al., 2005, McComsey et al., 2007)
To date, no RCTs have evaluated the influence of diet on iron or phosphate stores in patients with HIV infection.
Iron supplements have been given in conjunction with multivitamins to women with hepatitis C (Semba et al.,
2007) and improved iron stores and anaemia. The results from this trial cannot be generalised to the HIV infected
population as a whole due to the narrow inclusion criteria and short duration
Multi micronutrient formulations have shown a reduction in mortality in patients with a CD4 of <100 cells/mm3 in
Thailand (Jiamton et al., 2003), an increase in CD4 in the US (Kaiser et al., 2006) and an improvement in benefits
to mothers and offspring in Tanzania (Fawzi et al., 2004)
Vitamin D
Zinc
Selenium
Calcium
Iron and
phosphate
Other