Jan 29, 2015
Not Suitable

Whether it’s to peanuts, eggs, corn, or wheat, a food allergy can wreak havoc on an athlete’s nutritional plan. Here’s how to help them avoid and replace.

By Michelle Rockwell

Michelle Rockwell, MS, RD, CSSD, is a private sports nutrition consultant based in Durham, N.C. She works with athletes and teams throughout the country ranging from recreational to professional. She also offers sports nutrition consulting and workshops through RK Team Nutrition, at: www.rkteamnutrition.net.

In the past two weeks alone, I’ve had two athletes referred to me for food allergies. One is a high level marathon runner recently diagnosed with a gluten allergy (celiac disease), which means she has many dietary changes to make in a sport where bagels, sports bars, and pasta are staples.

The second athlete is a youth swimmer struggling with several allergies, and corn was recently added to the list. Avoiding foods with high fructose corn syrup, which is in so many baked goods, snack foods, and sports drinks, is in his future. He’ll need replacements for many everyday foods.

Research from the National Institute of Allergy and Infectious Disease indicates that one in three Americans modifies his or her diet based on a perceived food allergy. The actual incidence of medically proven food allergies is actually much lower. Nevertheless, the number is significant enough that sports medicine professionals working with athletes are likely to encounter food allergies on a somewhat regular basis.

Helping these athletes to get the most from their nutritional intake while maneuvering around the food they must avoid can be a huge challenge. It takes education, planning, and creativity. But these steps are critical if the athletes are to get the nutrients they need to continue training and competing to their best ability.


Food allergies, also known as food hypersensitivity, are immune reactions to a specific food component, usually a protein. Eight foods are responsible for 90 percent of all food allergies and are known as the Big 8: milk, eggs, peanuts, tree nuts (walnuts, cashews, chestnuts, Brazil nuts, hazelnuts, pecans), fish, shellfish, soy, and wheat.

But other foods can also cause allergies. They include corn, sesame, gluten (wheat plus several other grains), mollusks (oysters, mussels, clams, squid, octopus), certain fruits (particularly berries), and some food additives and preservatives (benzoates, salicylates, MSG, sulfite derivatives).

About 60 percent of allergies appear during the first year of life and are outgrown by grade school. But some allergies appear during the adolescent or adult years–milk and wheat especially. According to the Food Allergy and Anaphylaxis Network, six to eight percent of children under age three and two percent of adults have food allergies, totaling about 12 million Americans.

Allergic reactions to foods occur when the body’s immune defense system interprets a specific food as a toxin. For example, the immune system of someone with a peanut allergy recognizes peanuts or peanut-containing foods (called the allergen) as harmful invaders. In response, the immune system creates specific antibodies to protect the body. The antibodies, usually Immunoglobulin E (IgE), trigger the release of chemicals such as histamine into the blood stream, introducing a cascade of allergic symptoms that may affect the respiratory system, skin, gastrointestinal tract, and cardiovascular system.

This may result in the following common symptoms:

• Almost immediate tingling or burning in the mouth or swelling and itching around the mouth • Runny nose • Rash or hives • Abdominal cramping or diarrhea • Breathing difficulties such as wheezing or asthma • Vomiting or nausea.

More serious symptoms include:

• Swelling of the tongue, throat, and mouth • Airway obstruction • Severe vomiting • Anaphylaxis.

The most concerning symptom of food allergies, anaphylaxis, can lead to anaphylactic shock, which is life threatening and requires immediate medical attention. In fact, food allergy-related anaphylaxis is responsible for 200 deaths a year in the United States. Signs of anaphylaxis include difficult or noisy breathing, tightness of the throat, swelling of the tongue, difficulty talking, wheezing or persistent coughing, and/or loss of consciousness.

You also want to be aware of the risk of exercise-induced anaphylaxis. There are some food allergies that only occur when the food is consumed before strenuous exercise. If allergy-like symptoms arise seemingly unexplained, consider the situation an emergency and provide immediate medical attention.

Most allergic reactions do not occur the first time an allergen is consumed. This is because upon initial consumption, the immune system forms IgE antibodies that attach to certain mast cells in body tissues. It isn’t until the next time the allergen is eaten that the pre-disposed mast cells release the chemicals causing the allergic reaction.

The incidence of food allergies is increasing. Some theorize that there are evolving genetic and immune factors causing this shift. Others feel that there is simply more awareness of food allergies, leading to greater detection, reporting, and treatment. Another theory is called the “hygiene hypothesis.” Some scientists suggest that since many of today’s babies and children are exposed to fewer allergens and germs when young, they are more susceptible to allergens as they grow.

Peanut allergies have shown the greatest increase among Americans in recent years. This may be due to changes in standard peanut preparation. Peanuts are now commonly dry roasted, whereas boiling used to be a more common preparation method. The high temperatures used in roasting may change the proteins in peanuts, making them more allergenic.


Many people think they have food allergies when technically they have food intolerances. Although food intolerances may present with similar symptoms to food allergies, they are caused by different biological functions and are far more common than true food allergies.

Food intolerances do not involve the immune system. Rather, they are chemical reactions induced in various bodily systems caused by a certain food component. Although they can be quite problematic for some people, food intolerances are generally less severe than food allergies. Another distinction is that food intolerances usually take 12 to 24 hours to develop, whereas symptoms of food allergies occur immediately.

Symptoms associated with food intolerance often include:

• Nervousness • Excessive sweating • Rash or hives • Rapid breathing • Headache • Abdominal pain • Diarrhea • Burning sensations on the skin • Tightness across face and chest • Breathing problems • Nasal drip.

One common food intolerance affecting many athletes is lactose intolerance. Lactose is a natural sugar in milk that our bodies digest with help from the enzyme lactase. Individuals with lactose intolerance do not produce adequate amounts of lactase, and the undigested lactose combines with bacteria in their stomach to form gas. This can lead to discomfort, abdominal pain, and diarrhea.

One in 10 Americans is lactose intolerant, with a higher incidence in blacks and Asians. Avoiding lactose in foods means limiting milk-based products in the diet, including cheese, yogurt, ice cream, and anything prepared with milk. However, many lactose intolerant individuals can handle some level of milk-based products in their daily diets.

Other common food intolerances include citrus fruits, strawberries, chocolate, wine, and eggs. Intolerances can also occur when people eat foods with MSG (a preservative in some foods) or histamine (found in fish, some fruits and vegetables, fermented foods such as wine or some cheeses, and some food dyes).

There are also medical conditions common in athletes that have a relationship to food intolerances. Migraine headaches, asthma, and irritable bowel syndrome (IBS) can each be triggered by certain foods. Athletes with these conditions may want to explore their reactions to certain foods by using an elimination diet, which takes away possible triggers from the diet for about two weeks, then adds them back one by one. The following are common trigger foods related to medical conditions:

Migraine headaches: caffeine, coffee, alcohol (especially wine), aged cheeses, high sodium packaged foods, MSG-containing foods, packaged deli meats, some artificial sweeteners like aspartame.

Asthma: shellfish, nuts, soy, sulfite-containing foods such as wine, beer, canned soda, some fruit juices, and condiments (food label terms to look for include: sodium bisulfite, potassium bisulfite, sodium sulfite, sulfur dioxide, and potassium metabisulfite).

IBS: Coffee, alcohol, concentrated high sugar foods and drinks, highly seasoned or fried foods, some fruit juices, licorice, broccoli, cabbage, cauliflower, and sugar alcohols (food label terms to look for include: sorbitol, xylitol, maltitol, isomalt, lactitol, mannitol, erythritol).

You’ll also want to be aware of a few conditions and situations that present similarly to food allergies and intolerances, but are actually unrelated. Some examples include:

Food poisoning: A rapid-onset, extreme reaction to food may occur with food poisoning or food borne illness. A complete and thorough description of symptoms and foods consumed (along with their preparation, holding temperature, age, etc.) should help the healthcare team distinguish food poisoning from allergy or intolerance.

Psychological conditions: Mental health issues can cause poor tolerance of some foods for a variety of reasons. Food aversion related to prior experience with a specific food, phobia regarding that food, disordered eating, or extreme stress may induce symptoms that resemble food allergy.

Medication interaction: Although rare, it is possible for certain medications to react with specific food components to cause an adverse medical reaction. All worrying side effects related to medications should be discussed with a physician.

Other medical issues: Health conditions such as ulcers, gall bladder problems, or even viral infections may present with symptoms similar to food allergies. All individuals who have had an adverse reaction to a food should be screened by a physician to rule out other medical problems.


As you can see, diagnosing a food allergy is not easy. Differentiating an allergy from an intolerance from another medical condition often takes some legwork and trial and error.

Because of the seriousness of many of these conditions, anyone who experiences an adverse reaction to a food or beverage should be evaluated by a physician. The best scenario is to visit the doctor while the reaction is occurring so he or she can perform a first-hand examination of the symptoms. If an immediate visit is not possible, the individual or healthcare provider should keep a very detailed written account of the event. These questions should be answered:

• What foods were consumed over the past 24 hours, how were they prepared, and where did they come from? • What was eaten in the 15 minutes before the reaction occurred? • What types of symptoms occurred and how did they progress? • Did allergy medications (antihistamines) help any of the symptoms? • Did anyone else who ate the same food get sick?

The physician is likely to perform a “differential diagnosis” to determine the exact cause of the reaction. Knowing the cause is critical in advising individuals on what steps to take next.

If a food allergy seems to be the cause, the physician may want to conduct a test to figure out the allergen. One, the skin prick test, is often conducted right in the physician’s office. The technician places a drop of the allergen being tested (milk protein or egg protein, for example) on the individual’s skin, makes a small puncture to allow the potential allergen to enter, and then waits for a reaction (a small bump) on the tested skin area. A physician would not use the skin prick test if there was a history of anaphylactic symptoms.

A second common test for diagnosing a food allergy is known as RAST (radioallergosorbent test), which is also called ImmunoCap. The RAST is a blood analysis in which a lab tests antibodies in the blood sample for interaction with a variety of different food allergens.

The newest type of test is called a double-blind food challenge, and typically is more accurate than the previous two. However, it is more complicated. The patient is provided with capsules to consume each day for a specified period of time. The capsules either contain a specific food allergen or a placebo. Detection of symptoms can occur without the patient knowing whether or not a concerning food had been consumed.

If the symptoms seem more consistent with food intolerance rather than allergy, an elimination diet may be prescribed. During an elimination diet, it is important to replace any nutrients lost. For example, when wheat is the suspected problem, the individual would remove all regular breads, pastas, wheat-containing cereals, crackers, wheat bran, pancakes, sports bars, cookies, and so forth from his or her diet. The athlete can continue to meet carbohydrate needs with substitute foods such as rice, potatoes, rice or potato breads and pastas, oat cereal, fruits, veggies, and dairy products.

If milk and dairy are eliminated, replacing calcium through calcium-fortified orange juice, cereals, salmon, soy milk or cheese is important. Nutrient replacement is particularly critical for athletes whose training and health can suffer rapidly due to dietary deficiencies.

Two more pieces of information on diagnosing allergies:

• Understand that people with one allergy are more likely than the average person to develop other food allergies. If you work with someone who has a known allergy (even if it is not to food), observe any suspicious physical symptoms carefully.

• Be familiar with cross-reactivity with food allergies. This term is used to describe seasonal allergies affecting produce and causing food allergies. For example, during certain seasons of the year, people with pollen and ragweed allergies may have trouble eating certain foods like melons or corn. DEALING WITH IT

Once a diagnosis has been made, there is often a sigh of relief from the athlete. But there is still a tough road ahead as the athlete learns how to avoid the problematic foods and make replacements for them.

Identifying foods involves reading labels and understanding ingredients, which can be very challenging. The Food Allergen Labeling and Consumer Protection Act (FALCPA) passed in 2006 requires the following ingredients to be listed in plain language on food labels due to their allergen risk: milk, eggs, fish, crustaceans, shellfish, peanuts, tree nuts, wheat, and soy. Teach the athlete to always read the label before purchasing a new food, looking for the ingredient he or she is allergic to.

In the dining hall, ask staff to post ingredients, or at least to note the Big 8 allergens. Train the athlete to read these signs and ask food service workers if they have any questions.

Even for an athlete who has been dealing with a food allergy all of his or her life, learning to avoid the allergen in a new setting, such as a college campus, can be difficult. That’s why working with college freshmen who have food allergies is important. For example, I had an athlete experience beginning stages of anaphylaxis after a training table meal at which he consumed jambalaya. He had eaten jambalaya many times in the past at home, but when his parents prepared it, it never contained shrimp. He assumed no jambalaya contained shrimp and neglected to read the posted ingredients.

Also, educate athletes about the risk of cross-contamination. A meal served in a restaurant where the same utensils and work space are used for preparing many different dishes can be problematic. If the same knife cuts hard boiled eggs and green peppers for a salad, for example, a person allergic to eggs may have an allergic reaction even if they order the salad without egg.

Finally, recognize the risk of dietary supplements. Due to loose labeling standards in the U.S., dietary supplements may contain substances not listed on the label. I worked with a football player who had a peanut allergy and was extremely careful about reading labels before trying new foods. He used a lemon flavored recovery drink after one of his workouts, which he assumed to be safe because there was no mention of peanuts on the label. But there were traces of peanut in it and he had an allergic reaction requiring medical treatment. Some supplements also contain derivatives of allergen foods athletes may not be aware of. Individuals with a shellfish allergy, for example, should not use chondroitin or glucosamine/chondroitin supplements.

Figuring out how to replace the nutrients in foods that cause allergy can also be a challenge. Fish, shellfish, soy, and nuts are usually not problematic as they are not staples of our diet, but gluten, wheat, milk, and eggs need special attention.

Athletes who follow a gluten-free diet must pay particular attention to dietary modifications. It’s not only critical to focus on avoiding wheat, barley, rye, and oats, but on replacing the carbohydrates and fiber missing when these are eliminated. Appropriate alternatives may include all types of potatoes, all rice varieties (except packaged rices that come with sauces thickened with wheat flour), rice cereals that don’t contain other grains or malt, fruits, and vegetables. Athletes can look for “gluten-free” on labels and also read the fine print on the ingredient list. The good news is that more and more stores are starting to carry gluten-free products, including pastas, bread, crackers, and even granola bars made primarily with rice or potatoes.

When only wheat needs to be avoided (and not all gluten-containing ingredients), it’s possible to replace missing carbohydrates through potatoes, rice, oat or rice cereals, dairy products, fruits, and vegetables. The toughest times for these athletes tend to be pregame meals and eating on the road. Those responsible for arranging team meals should be certain that rice or potatoes are on the menu and that entrees and side dishes are prepared without wheat products. For example, be sure meat dishes are not breaded, salads do not contain croutons, and soups or vegetables are not thickened with flour. Athletes should travel with wheat-free canned soup, oatmeal packets, rice cakes, and potato or rice bread.

Athletes allergic to milk must focus especially on alternative calcium-containing foods. Soy milk, soy cheese, and soy yogurt can be an excellent replacement for cow’s milk as most are fortified with calcium. Calcium-fortified fruit juices and cereals can be helpful in addition to foods naturally containing calcium such as salmon, almonds, and leafy green vegetables. Keeping in mind that dairy is the best source of calcium and that athletes need three to five serving per day (1,000-1,500 mg of calcium), it’s likely that a calcium supplement will be warranted.

Athletes with milk allergies must also avoid many of the popular recovery shakes. Post-exercise recovery nutrition needs can be met through milk-free snacks such as fruit smoothies with soy protein powder, trail mix, or peanut butter on crackers.

Egg allergies are complicated not because it’s difficult to avoid whole eggs, but because so many products are prepared with eggs. Most baked goods (pancakes, muffins, cookies, crackers) contain eggs. Processed snacks, breaded meats (such as chicken tenders), and sports bars often contain eggs as well. It’s possible to replace the protein in eggs with meat, nuts, peanut butter, milk and dairy products, beans, and soy or tofu.

Click here for a chart that shows a quick look at how to avoid and replace the nutrients in common allergens.


Finally, all athletic trainers and coaches working with athletes need to know how to treat an allergic reaction. Anyone with a history of anaphylaxis should have 24-hour access to adrenaline or epinephrine. This is prescribed by a physician in the form of an EpiPen or Twinject.

If an individual determines that he or she has consumed a food they are allergic to (or if they feel related symptoms), they need to immediately inject the EpiPen. Athletic trainers should keep EpiPens in their medical kits for at-risk athletes. Less severe reactions (hives, runny nose, itching, etc.) can be treated with antihistamines or creams.

If an athlete goes into anaphylactic shock and medication is not available, opening the airway is critical. Rescue breathing should be initiated, and emergency assistance should immediately be called. Failing respiratory function can lead to organ damage, including brain damage.

Hopefully, you’ll never have to respond to such an emergency and your work with athletes who have allergies can focus on prevention. The keys are accurate diagnoses, education on ingredients, and finding appropriate replacement foods.

Resources: Food Allergy & Anaphylaxis Network: www.foodallergy.org

International Food Information Council: www.ific.org

Mayo Clinic: www.mayoclinic.com

Asthma and Allergy Foundation of America: www.aafa.org

National Institute of Allergy and Infectious Disease: www.niaid.nih.gov

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