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Of Food Allergy, Physics, and The Heisenberg Uncertainty Principle 

Ever see a medical article that seems to go viral, and have a life of its own?   A recent article in JAMA by Drs. Chaffen, Newbury et al. entitled "Diagnosing and Managing Food Allergies--A Systematic Review--popped up on my radar screen.  The article was picked up and commented on by the NY Times, in an article with the unsavory title "Doubt is Cast on Many Reports of Food Allergies".  Everywhere I turned, it seemed--and every email I opened--seemed to be commenting on the article.  Everyone--my patients and colleagues--commented on it. Finally, one of my blog readers (I liken them to Marines--"the few, the proud"...) sent me the nth copy of the article, but with this accompanying comment:

  "Perhaps you've already seen this article--I think it is interesting that the concept of total allergic load is completely absent...If a patient is beneath the threshold, I can well imagine that solitary food challenges do not bring out a reaction, whereas avoidance and rotation according to low-level responses in skin and blood tsts may well help lower the load, lessening the probability of an allergic response"

 Wow.  Seldom have I had a comment from a reader that resonates with my feelings so completely. What he is really highlighting is the importance of the Total Allergic Load, something I've blogged on before.  It is very dismaying that when the NY Times held a forum entitled "The Squishy Science of Food Allergy" which provided a dialogue between experts as they weighted in on the topic of food allergy, not one of them commented on the importance of the Total Allergic Load as it relates to Food Allergy.

Food allergy always "participates" in a patient's illness within the context of the patient's total allergic and stress load.  Any attempt at studying food allergy "in isolation" is going to be met with problems... As an allergist for 29 years, examples of the dynamic, fluid nature of food allergy abound:

Example 1:  a boy who knew he was egg allergic strictly avoided eggs.  He ate chicken 2 or 3 times a week without a problem.  Then one day, he went outside, shoveled snow, came inside, and on an empty stomach had chicken soup at lunch.  Result?  A quick trip to the ER for a severe reaction.  The exercise, coupled with a liquid form of the allergen on an empty stomach caused a reaction to chicken, even though he "normally" ate it 2 or 3 times per week.  Silverstein's article on "Celery-dependent, Exercise-induced Anaphylaxis"  is "spot on" in this regard.  He reported a case wherein a patient could exercise, or could eat celery, but not do both together without anaphylaxis.  A perfect example of The Total Allergic Load. 

Example 2:  a woman who had discovered that she could eat corn 11 months a year without problems, but at the height of the grass allergy season, ingestion of corn caused diarrhea.  

Example 3:  a woman I diagnosed as having urticaria from wheat, with an IgE RAST III score to it, was treated by me with SLIT. Her IgE titer reduced by 75% on SLIT, and she subsequently was able to eat wheat without any reaction at all, --until the tragic death of her granddaughter.  She came in to see me at the office, covered in hives, and the hives resolved when wheat was eliminated in her diet once again, even though RAST was only IgE class I.  

My reader's comment which I quoted above highlights a fundamental concept missing from the debate...an immutable law of food allergy never stated but nevertheless in full operation every moment. Here are my two "thoughts":

Postulate (Which I will call "The Food Allergy Uncertainty Principle") :  The very act of studying food allergy in an isolated manner alters the findings of the ultimate incidence of food allergy.

Corollary:  The true incidence of food allergy can never be known.   

In a sense, this reminds me of the Heisenberg Uncertainty Principle we studied in college during my engineering years..i.e., in  quantum physics,  the Heisenberg Uncertainty Principle states that one cannot simultaneously know both the position and the momentum of a given object to arbitrary precision.  In a sense, the Heisenberg Uncertainty Principle is really discussing the observer effect--i.e., the measurement of position necessarily disturbs a particle's momentum, and vice versa.  In a similar manner, the "measurement" of a specific food allergy, by double-blinded placebo controlled study, may determine it's position of reactivity at any one point in time, but cannot measure it's "momentum"--i.e., buildup effect and contribution to the total load over time in a random fashion.   By observing for an isolated food reaction, you are creating an arbitrarily artificial scenario and in a sense "disturbing" the Total Load Effect.   

Physics?  Allergy?  Do they have something in common?  I like to think so.  I think of food allergy as something incredibly dynamic, a fascinating "force" dependent on mass (amount), time, successive days of exposure (momentum), and total allergy load (critical mass).  

So what is the true incidence of food allergy?  In my opinion, it can never be measured, per "The Food Allergy Uncertainty Principle".  The act of isolated measuring alters the outcome from "real life".  But I don't need to know the true incidence.  I just know there are alot of suffering patients out there.  And you know what?  Many, many of them have food allergy.  And that's a statistic I can live with.

Later, 

Dude

Posted on Sunday, May 23, 2010 at 04:30PM by Registered CommenterGeorge F Kroker MD FACAAI | Comments1 Comment

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Reader Comments (1)

Dr. Kroker,

Just doing some catch up reading, thoroughly enjoyed The Chair. However, wanted to comment on the....Uncertainty Principle discussion especially as it relates to the problems with explaining research outcomes, specificaly the gold standard DBPC. I come from a business background where in under- graduate and MBA classes we looked at idustrial/operational experiments and always had to be aware of the "Hawthorne Effect" (see this link for detail review http://en.wikipedia.org/wiki/Hawthorne_effect)

Research is an imprecise science.

June 17, 2010 | Unregistered CommenterJeff K

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