Rare Conditions With Nutrition Implications: Alpha
As dietitians, we are familiar with the top eight food allergens: wheat, soy, eggs, cows milk, fish, shellfish, peanuts, and tree nuts. What aboutred meat? Meet the alpha-gal allergy. Its a rare condition that is becoming more common. Because of the obvious nutrition implications, dietitians are often called upon to educate patients, clients, families, foodservice staff, and other healthcare providers how to navigate this unique condition.
What is alpha-gal allergy?
Alpha-gal is short for galactose–1,3-galactose, a sugar molecule. This molecule differs from most food allergies because the allergen is a carbohydrate rather than a protein molecule. The alpha-gal molecule is found within the saliva of the Lone Star tick, as well as other potential arthropods after they have been feeding on mammalian blood. However, within the United States, the Lone Star tick is the primary cause. This sugar molecule exists in most mammalian meat . It can also be found in mammalian by-products, like cows milk, gelatin, and the cancer treatment medication, cetuximab. On the other hand, animal by-products obtained from chicken, turkey, and fish do not contain alpha-gal.
Nutrition implications of alpha-gal allergy
How dietitians can help
We are still learning more about alpha-gal allergy. Research is optimistic, indicating that some individuals may be able to reintroduce mammalian meats back into their diets after a period of abstinence, as long as no additional tick bites have occurred.
Avoidance Of Mammalian Meat
The primary advice for newly diagnosed patients with AGS is to completely avoid meat of mammals . In most areas of the U.S. this means beef, pork, venison and lamb. Internal organs are equally or more able to induce reactions and these should be avoided as well, especially pork kidney . Equally, fattier forms of meat are more consistently associated with symptoms and more severe reactions upon challenge . Cooking does not appear to significantly denature the alpha-gal epitope but, in our experience, may reduce reaction severity likely through reduction in fat content . Meat and products derived from other mammals such as bison, buffalo, rabbit, horse, and goat should equally be avoided . Patients do report symptoms with exposure to fumes from mammalian meats/fats being cooked however, no blinded challenges have been published to definitively document the airborne route of exposure. Interestingly, experience suggests fumes may pose a more potent risk to reactive patients than moderate levels of pet dander exposure. As with other food allergies, we take an individualized approach to management of AGS . This includes not only dietary avoidance advice but also nutritional management, discussion of labeling issues and hidden exposures, awareness of individual eliciting threshold doses and the possible influence of tick bites, as well as use of masks for fume-sensitive patients, inhaled beta-agonists, prophylactic anti-histamines and even omalizumab.
What Is The Treatment For Tick Bite
The prevention of tick bites is paramount through both using insect repellents and avoiding forested areas.
People with tick bite-induced red meat allergy should avoid red meat and other substances with alpha-gal.
The treatment of the allergic response includes antihistamines, oral steroids, and, in the case of anaphylaxis, adrenaline.
The use of desensitisation by exposing the patient to large amounts of alpha-gal is undergoing investigation .
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What Should I Do If I Think I Have Ags
- AGS should be treated and managed by an allergist or other healthcare provider.
- Many foods and products contain alpha-gal you will need to work with your healthcare provider to understand which products you need to avoid. Not all patients with AGS have reactions to every ingredient containing alpha-gal.
- Most healthcare providers recommend patients with AGS stop eating mammalian meat .
- Depending on your sensitivity and the severity of your allergic reaction, your healthcare provider may also suggest you avoid other foods and ingredients which may contain alpha-gal .
- Although very rare, some people with severe AGS may react to ingredients in certain vaccines or medications. Talk to your healthcare provider before taking a new medication or receiving a vaccine.
- Patients with AGS should avoid tick bites. New tick bites may reactivate allergic reactions to alpha-gal.
What Patients Should Know About Alpha
Lone Star Tick
The most common foods that cause allergic reactions in people are milk, egg, fish, wheat, shellfish, tree nuts, peanuts, and soybeans. However, there have been reports of allergic reactions to many other types of foods, including red meat. Research shows that for a red meat allergy, unlike many food allergies, the cause can be connected to an environmental factor, a tick bite.
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Causes And Risk Factors
People arent born with an allergy to alpha-gal. Almost anyone who has an alpha-gal allergy develop it as an adult, though children can get it. Bites from the lone star tick have been shown to cause alpha-gal allergies. Some research argues that ticks are the only real cause of this sort of allergy.
Ticks contain alpha-gal. A tick bite triggers your immune system to react to alpha-gal as a defense mechanism. The antibodies that your body makes to protect you from the tick bite remain in your system. These antibodies will then combat alpha-gal when you eat meat that contains it.
Living in areas where lone star ticks are prevalent puts you at a higher risk of this happening. The lone star tick lives primarily in the southeastern and eastern United States.
What Does Treatment Look Likeand Does Alpha
The only way to treat a food allergy is through avoidance, so if youve been diagnosed, then youll have to avoid all types of mammal meat. We tend to think of it as just burgers and steak, but it means you cant have cow, pig, lamb, sheep, deer, or goat meat, says Dr. Commins. Dairy, like butter and cheese, shouldnt be a problem.
REPEL Plant-Based Lemon Eucalyptus Insect Repellent
REPEL Plant-Based Lemon Eucalyptus Insect Repellent
Its fairly easy to avoid red meat at home, but when youre out at a restaurant, cross-contamination is possible, so your doctor will likely suggest you carry an epinephrine auto-injector with you. We tend to treat this in a similar way to a kid who has a peanut allergy, Dr. Commins says.
Luckily, youre not sentenced to a lifetime sans burger. Eventually, people seem to get over alpha-gal allergy one 2018 study published in JAMAnoted it was after 18 months to three years of a meat-free diet.
Then, do your best to avoid getting subsequent tick bites. Tick repellents containing DEET, picaridin, and oil of lemon eucalyptus are your friends, meat lovers.
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What Is Tick Bite
Tick bite-induced red meat allergy is an allergy to the carbohydrate galactose-alpha-1,3-galactose , which is present in both tick bite saliva and red meat . Tick bite-induced red meat allergy is also called alpha-gal allergy.
Sensitisation to alpha-gal follows a bite from particular species of tick. Subsequently, eating red meat may result in itching, urticaria, angioedema, gastrointestinal upset, and rarely, anaphylaxis .
Red meat
A Warning About Gelatin
Parenteral administration of medical products that contain bovine or porcine gelatin is considered even more risky for patients with AGS than consumption of red meat . This risk is not ruled out by negative results for sIgE to gelatin. Individuals who are sensitized to alpha-gal may experience anaphylactic reactions to parenterally administered gelatin despite testing negative for sIgE to gelatin .
Bakhtiar, et al write:
It appears that the diagnosis of alphagalrelated gelatin sensitisation and allergy may readily be missed by a conventional gelatin sIgE assay. Possibly, the allergenic target for the gelatin immunoassay does not include the alphagal moiety .
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Notes About Your Symptoms When They Occurred And What Foods You Ate Prior To The Onset Of Symptoms
Symptoms
Include information about the following symptoms and any other symptoms you have experienced:
- Classic allergic symptoms, including any rashes or swelling
- Gastrointestinal symptoms, like pain, cramping, diarrhea, vomiting, or heartburn
- Joint pain/arthritis
- Include information about any foods you ate within ten hours prior to developing symptoms.
Medications/medical products
- Bring a written list of any medications and/pr supplements that you take.
- Note any adverse reactions you have had to medications, vaccines, or other medical products.
How Do I Manage My Allergy
Your healthcare provider may recommend a plan that includes the following.1,2,4,8,11,12
Your healthcare provider may direct you to take one of the following medications to improve your allergy symptoms:
- Antihistamines for ongoing pruritus .
- Oral corticosteroids to limit swelling with angioedema .
If someone youre with is having an allergic reaction and showing signs of shock, act quickly. Look for a weak, rapid pulse trouble breathing cool, clammy, and pale skin confusion and loss of consciousness. Immediately do the following:
- Ensure the affected individual is lying down with legs elevated.
- Administer epinephrine immediately for any obvious signs of anaphylaxis.
- Check the affected individual’s pulse and breathing and administer CPR or other first-aid measures if necessary.
Looking for more allergy info and management tips?
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Ive Been Diagnosed With Ags Whats Next
Depending on the severity of your symptoms, the diagnosis will typically mean a significant change in your diet, according to Dr. Kriete.
All red and mammal meats will need to be avoided, Dr. Kriete said. Some patients, but not all, will find they also need to avoid dairy products. A complete list of foods to avoid can be found on the Centers for Disease Control and Preventions website. The following foods do NOT contain alpha-gal: poultry eggs fish and seafood and fruits and vegetables.
For most people, the symptoms are a mild nuisance, and there is no need to worry about cross-contamination. For patients with more severe reactions, however, cross-contamination can be a major concern.
Blood Testing Is Paramount In Testing For Alpha
Given the time and money that can be involved in securing a diagnosis, testing for alpha-Gal syndrome is critical. There is no explicit AGS treatment, so itâs vital to receive a proper diagnosis to know what products and foods to avoid.
How do you test for alpha-Gal syndrome? You need to get the right test straight out of the gate, and a skin-prick test probably isnât the way to go. In fact, SPTs with extracts of pork or beef have been unreliable in detecting alpha-Gal.9
Is there a test for alpha-Gal?
Yes. You can ask your healthcare provider for an alpha-Gal allergy blood test. But instead of a whole allergen blood test, which helps providers rule allergies in or out, an allergen component test for alpha-Gal allergy may help to pinpoint the specific sugar molecule that is causing symptoms. Plus, allergen component testing may offer providers insight into the severity of an individualâs reactions.
However, it may not be enough just to ask for an allergy test. You need to be specific to ensure you get the right one: an alpha-Gal IgE test. To be even more specific, you want an alpha-Gal specific IgE component test. Additionally, your provider may want to test for beef, pork, lamb, and tryptase to help develop a clear diagnosis.
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Avoidance Of Dairy Products
We do not routinely include avoidance of dairy products as part of primary avoidance, as 80-90% of patients with AGS do not react to milk or cheese . However, published evidence and expert opinion articles indicate that full avoidance of dairy products perhaps should be recommended in patients already avoiding mammalian meat without adequate control of symptoms .
Managing A Severe Food Reaction With Epinephrine
A food allergy, including a meat allergy, can cause symptoms that range from mild to life-threatening the severity of each reaction is unpredictable. People who have previously experienced only mild symptoms may suddenly experience a more severe reaction, including anaphylaxis. In the US, food allergy is the leading cause of anaphylaxis outside the hospital setting.
Epinephrine is the first-line treatment for anaphylaxis, which results when exposure to an allergen triggers a flood of chemicals that can send your body potentially into shock if not treated promptly. Anaphylaxis can occur within seconds or minutes, can worsen quickly, and can be deadly.
Once youve been diagnosed with a food allergy, your allergist will likely prescribe an epinephrine auto-injector and teach you how to use it. Check the expiration date of your auto-injector, note the expiration date on your calendar, and ask your pharmacy about reminder services for prescription renewals.
If possible, have two epinephrine auto-injectors available, especially if you are going to be far from emergency care, as the severe reaction may reoccur. Epinephrine should be used immediately if you experience severe symptoms such as shortness of breath, repetitive coughing, generalized hives, tightness in your throat, trouble breathing or swallowing, or a combination of symptoms from different body areas such as hives, rashes, or swelling on the skin coupled with vomiting, diarrhea, or abdominal pain.
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Prevention And Tick Removal
Tick bites can be prevented by treating clothing and gear with products containing 0.5% permethrin and by avoiding areas inhabited by ticks.
Debate exists around the best method of tick removal although recent consensus is to freeze them with an ether-containing spray .
What Blood Tests Do Doctors Use To Help Them Diagnose Alpha
With a convincing clinical history, alpha-gal IgE levels at least 0.1 kU/l confirm the diagnosis of alpha-gal syndrome. With a murky clinical history, some have argued that an alpha-gal IgE at least 2 kU/l or at least 2% of the total IgE should be used to confirm the diagnosis of alpha-gal syndrome .
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How Do I Know If I’m Allergic*
Skin-prick tests with extracts of pork or beef have been unreliable in diagnosing alpha-Gal syndrome. While intradermal skin tests for several food allergens may be useful, few clinics perform such testing. Thus, most allergists rely on a blood test for IgE to identify alpha-Gal.4
Together with your symptom history, specific IgE blood testing can help determine if you are sensitized to a particular allergen. If you are diagnosed with an allergy, your healthcare provider will work with you to create a management plan.
*These products may not be approved for clinical use in your country. Please work with your healthcare provider to understand availability.
Other Foods That May Or May Not Be A Source Of Alpha
Limited data and/or anecdotal evidence suggest that some foods that do not obviously contain mammal or red algae derived ingredients can cause reactions in some people with AGS for reasons that arent clear. These include:
- Possibly some other types of edible fish roe , although as far as we know, there is no evidence that salmon roe, flying fish roe, herring roe, or caviar are a problem.
- Koji is made from aspergillus , which expresses alpha-gal .
- There is a lack of data as to whether koji can cause reactions in people with AGS, but most of us seem to tolerate products like miso and soy sauce that are made from it.
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Across The Globe Bites From Several Types Of Ticks Can Lead To Alpha
Initially, this syndrome was linked to the Lone Star Tick, which is found mostly in the southeastern United States.2 However, Alpha-Gal Syndrome has now been reported on all continents except Antarctica, and at least eight tick species are confirmed or suspected culprits associated with the condition.5
Additionally, at least some tick species have extended beyond their typical home turf. That is, as hosts such as deer move into different territories, so do ticks that hitch a ride on them. So thanks to different patterns of land use, climate change, and increasing deer populations, ticks like the Lone Star Tick have spread. For example, the Lone Star Tick was previously rare in Michigan, but itâs now the third most common tick in the state.4 Plus, a 2022 article in the Toronto Star revealed that the tick is expanding into Canada due to rising temperatures.13
Also note that many tick bites go unnoticed, particularly from âseedâ ticks. Although these baby ticks are the size of a poppyseed, they can still transmit alpha-Gal.4 Recent reports also suggest that bites from chiggers, which are microscopic arachnids that can be found worldwide, may also lead to Alpha-Gal Syndrome.3,6,14
Alpha-Gal Syndrome is transmitted via multiple tick species and has been reported on all continents except Antarctica.5,11
What Should I Do If I Have Ags
- AGS should be treated and managed under the care of an allergist or other healthcare provider.
- Many foods and products contain alpha-gal you will need to work with your healthcare provider to understand which products you need to avoid.
- Prevent tick bites. New tick bites may reactivate allergic reactions to alpha-gal.
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For The Majority Of Patients In One Study It Took Seven Years To Obtain An Alpha
While info on alpha-Gal Syndrome is offered by many medical-information sources, such as the Centers for Disease Control and Prevention , the condition is still relatively unknown.1,4,20 In fact, one study revealed that almost 80 percent of patients with alpha-Gal syndrome struggled to find a diagnosis for more than seven years.20
Whatâs even worse is that in trying to determine the cause of their symptoms, some patients underwent exploratory surgery, removal of their gallbladder or appendix, and partial removal of the pancreas before they finally received an alpha-Gal Syndrome diagnosis.5 And according to a 2017 paper, patients are more likely to discover alpha-Gal online, on the radio, or through personal connections than by visiting the emergency room due to anaphylaxis.20
These stats are particularly troubling because an alpha-Gal IgE simple blood test can help a healthcare provider diagnose this syndrome. In fact, a single visit with your healthcare provider and a blood draw could help save you not only a boatload of time and money otherwise spent on specialists and unnecessary tests but also a mountain of misery.
