LEARNING OUTCOMES

1. Identify the most common food allergens.

2. Differentiate between food allergy and food intolerance.
3. Describe the symptoms and management of food allergies.
4. Identify testing that is used to diagnose and confirm food
allergies.
5. Name the most common food offenders and their
expected symptoms.
6. Explain how nutritional status is affected by food allergies.
7. Educate children and their caregivers about the
management of allergies while maintaining adequate
nutrition.
 Adverse reactions to food (ARF)- cover both food allergies
and intolerances which can result to distressing symptoms and
affecting a person’s quality of life.
Food allergy – is an adverse immune- mediated reaction to a
food, usually a food protein, glycoprotein, or happen that the
person has been sensitized to, and which, when eaten, causes
Definitions of the release of inflammatory mediators or chemicals that act
on body tissues and result in symptoms.
Terms Food intolerances – is an adverse reaction to a food or food
additive that does not involve the immune system and results
from the body’s inability to digest, absorb, or metabolize a
food or component of the food. They are caused by non-
immunologic mechanisms including toxic, pharmacologic,
gastrointestinal, genetic, metabolic, psychogenic, or
idiosyncratic reactions.
Introduction
Allergy refers to an excess sensitivity to
substances or conditions such as food; hair;
cloth; biological, chemical, or mechanical
agents; emotional excitement; extremes of
temperature; and so on.
The substance that triggers an allergic reaction
is called an allergen or antigen, and it may
enter the body through ingestion, injection,
respiration, or physical contact.
Introduction
In food allergies, the offending substance is
usually, though not always, a protein. After
digestion, it is absorbed into the circulatory
system, where it encounters the body’s
immunological system. If this is the first
exposure to the antigen, there are no overt
clinical signs. Instead, the presence of an
allergen causes the body to form
immunoglobulins (Ig): IgA, IgE, IgG, and IgM
Introduction
Although food allergy is not age specific, it is more prevalent
during childhood. Because a reaction to food can impose stress
and interfere with nutrient ingestion, absorption, and digestion,
the growth and development of children with food allergies can
be delayed.
In clinical medicine, it is extremely important to differentiate
food allergy from food intolerance. The former relates to the
immune system of the body, while the latter is the direct result
of maldigestion and malabsorption due to a lack of intestinal
enzyme(s) or an indirect intestinal reaction because of
psychological maladjustment.
Definitions of Terms

Antigen – is any molecule Food Sensitivity - is used

that will elicit an immune when it is unclear whether
response in the body. When the reaction is
it elicits a hypersensitivy immunologically related or
reactions as in allergy, it is due to a biochemical or
called an allergen. physiologic defect
 Angioedema: swelling and spasm of the blood
vessels, resulting in wheals.

Asthma: “panting,” respiratory spasm and wheezing

in an attempt to get more air.
Definitions of
Terms Bronchitis: inflammation of the mucous membranes
of one of the tubes leading to the lung.

Challenge diet: a diet designed to elicit a reaction by

deliberately feeding a person certain ingredients,
assuming the person is reactive to them.
 Dermatitis: inflammation of the skin with symptoms such as itching, redness,
and so on.

Eczema: acute or chronic inflammation of skin and immediately underneath it,

with symptoms such as pus, discharge, and itching.

Elimination diet: a diet with certain ingredients removed, assuming a person is

reactive to such ingredients. The disappearance of symptoms assumes that the
person is reactive to the missing ingredients.
Definitions of Immunoglobulin (Ig): one of a family of proteins that are capable of forming
antibodies.
Terms
Mastitis: inflammation of the breasts.

Purpura: a variety of symptoms; for example, hemorrhage into skin.

Urticaria: eruption of the skin with severe itching.

Etiology of ARF
Allergic reactions to food are posited to have numerous factors resulting
to a wide array of symptoms These include:
◦ genetics and epigenetics
◦ intestinal barrier integrity
◦ microbiota and loss of biodiversity
◦ maternal and early fetal life factors (cesarean delivery and lack of
breastfeeding)
◦ stress - psychologic factors
◦ exercise environmental and physiologic influences such as changes in
hormone levels
 The pathophysiological mechanism of ARFs
can be described in three phases, namely:

1. the breakdown of oral tolerance;

Pathophysiology
of food allergies
2. allergen sensitization; and

3. reactivity to allergens leading to allergy

symptoms
Symptoms associated with food
allergies
The symptoms of food
allergy involve multiple
organs systems, including
the dermatologic,
respiratory, gastrointestinal,
and neurologic systems.
SYMPTOMS AND MANAGEMENT
The clinical management of food allergy is controversial and has many
problem other difficulties in allergy management are as follows:
1. If a person is allergic to a food, even a very small amount can produce a
reaction.
2. Some patients allergic to an item at one time are not allergic at another.
3. Some patients react to an allergen only when they are tired, frustrated,
or emotionally upset.
4. Although protein is suspected to be the substance most likely to cause
allergy, people can be allergic to almost any food chemical.
SYMPTOMS AND MANAGEMENT
In managing patients with food allergy,
there are two basic objectives.
◦ First, the offending substance must be
identified.
◦ Patients should then be placed on a
monitored antiallergic diet to assure
adequate nutrient intake, especially young
patients whose growth and development
may be adversely affected by the allergy.
Symptoms associated with food
allergies
Dermatologic (Skin, mucus
membrane and eyes, ears, nose and
throat)
- itching
- hives a
- atopic dermatitis
- skin swelling and redness
- itchy, watery and reddened eyes
Symptoms associated with food
allergies
Gastro-intestinal abdominal
pain bloating and distention -
nausea and vomiting
indigestion and belching
diarrhea and constipation -
oral and pharyngeal itching
Gl bleeding
Symptoms associated with food
allergies
Systemic and nervous system
- migraine
- listlessness
- hyperactivity
- irritability
- chillness
- dizziness
- anaphylaxis
- hypotension
- dysrhythmia
Symptoms associated with food
allergies
Others
- frequent urination
- bed wetting
- muscle aches
- excessive sweating
- low grade fever
Signs and Symptoms of Food Allergy
DIAGNOSIS AND TREATMENT
Food allergies are difficult to test for and
subsequently to diagnose and confirm.
Furthermore, patients with an allergic
reaction to one food may in reality be
allergic to many others that contain a
common ingredient. Or, when an infant is
allergic to a formula, it is usually assumed
that the protein is responsible.
Detailed History
A detailed history is the most valuable tool for diagnosing food allergy. Your provider will ask you
several questions and listen to your history of food reactions to decide if the facts fit a food
allergy. The following are samples of such questions:
1. What was the timing of your reaction?
2. Did your reaction come on quickly, usually within an hour after eating the food?
3. Did allergy medicines help? Antihistamines should relieve hives, for example.
4. Is your reaction always associated with a certain food?
5. Did anyone else who ate the same food get sick? For example, if you ate fish contaminated
with histamine, everyone who ate the fish should be sick.
Diet Diary
This diet diary gives more detail from
which you and your provider can see
if there is a consistent pattern in your
reactions.
 The next step some healthcare
providers use is an elimination
diet.
In this step, which is done under
your provider’s direction, certain
Elimination Diet foods are removed from your diet.
You don’t eat a food suspected of
causing the allergy, such as eggs.
You then substitute another food-
in the case of eggs, another
source of protein.
Skin Test
If your history, diet diary, or elimination
diet suggests a specific food allergy is
likely, your healthcare provider will
then use either the scratch or the prick
skin test to confirm the diagnosis.
 Your healthcare provider can make a
diagnosis by doing a blood test as well.
Indeed, if you are extremely allergic and
have severe anaphylactic reactions, your
Blood Test provider can’t use skin testing because
causing an allergic reaction to the skin test
could be dangerous. Skin testing also can’t
be done if you have eczema over a large
portion of your body.
Implications
1. Diet therapy is used to identify allergic reactions and also to avoid these reactions.
2. Newborns of parents with allergies should be protected from potential allergens in
breastmilk.
3. Breastmilk is the best food for a potentially allergic infant.
4. Pregnant women with a family history of allergies should avoid foods known to be allergens to
reduce the risk of sensitizing the infant.
5. Solid foods should be introduced one at a time and evaluated over several days before adding
another.
6. Delay introduction of solid foods in an infant’s diet to reduce absorption of potential allergens
in an immature GI tract.
Implications
7. Appropriate substitutions or supplementation of an allergic child’s diet is essential to prevent
malnutrition created by gaps in permitted foods.
8. Children who are allergic to eggs should never be immunized with vaccines grown on chick
embryo.
9. Diabetic children allergic to pork are unable to use insulin made from hog pancreas.
10. Children with allergens should wear medical alert tags.
11. Allergens are usually (though not always) proteins.
12. Raw foods are more likely to be allergens than cooked ones.
13. Parents and children should read all labels carefully and be taught to look for hidden sources
of the allergen.
Implications
14. Foods that cause immediate allergic reactions in susceptible individuals are eggs, seafood,
nuts (especially peanuts), and berries.
15. Foods that cause delayed reactions are wheat, milk, legumes, corn, white potatoes,
chocolate, and oranges (citrus).
16. Patients who are allergic to a specific food will react to other foods in the same family.
17. Foods that cause allergic responses may be reintroduced at a later time because children
tend to outgrow food allergies.
18. Differentiate between food allergies and food intolerance. The treatments are very different.
COMMON ALLERGENS
Cow’s Milk
The allergen in cow’s milk is probably the most common. A susceptible person may be allergic to
whole, skimmed, evaporated, or dried milk, as well as to milk containing products such as ice
cream, cheese, custard, cream and creamed foods, and yogurt.
Milk allergy can range from a mild to a severe stage. As a result, for those with more severe form
of milk allergy, even butter and bread can create a reaction.
Symptoms can include either or both constipation and diarrhea, abdominal pain, nasal and
bronchial congestion, asthma, headache, foul breath, sweating, fatigue, and tension.
COMMON ALLERGENS
Kola Nut Products
Chocolate (cocoa) and cola (a source of caffeine) are products
obtained from the kola nut, as indicated in most health documents
issued by government agencies.
COMMON ALLERGENS
Corn
Because corn syrup is widely used commercially, corn allergy can result from a wide variety of
foods. Candy, chewing gum, prepared meats, cookies, rolls, doughnuts, some breads, canned
fruits, jams, jellies, some fruit juices, ice cream, and sweetened cereals often contain corn syrup.
Additionally, whole corn, cornstarch, corn flour, corn oil, and cornmeal can cause allergic
reactions to such foods as cereals, tortillas, tamales, enchiladas, soups, beer, whiskey, fish sticks,
and pancake or waffle mixes.
Symptoms can be bizarre, ranging from allergic tension to allergic fatigue. Headache can take the
form of migraine.
COMMON ALLERGENS
Eggs
Those with severe allergy to eggs can react to even their odor. Egg allergy can also cause
reaction to vaccines, since they are often grown on chicken embryo. Allergic reactions are
generally to such foods as eggs themselves, baked goods, candies, mayonnaise, creamy
dressings, meat loaf, breaded foods, and noodles.
Symptoms can be widely varied, as with milk. Egg allergy often results in urticaria (hives) though,
like chocolate, larger amounts are usually necessary to produce that symptom. Other symptoms
include headache, gastrointestinal allergy, eczema, and asthma.
COMMON ALLERGENS
Peas (Legumes)
The larger family of plants that are collectively known as peas include peanuts, soybeans, beans,
and peas.
Peanuts tend to be the greatest offender, and dried beans and peas cause more difficulties than
fresh ones. Products that can cause selected allergy reaction are honey (made from the
offending plants) and licorice, a legume.
Soybean allergy presents a problem similar to corn owing to its widespread use in the form of
soybean concentrate or soybean oil.
Legume allergies can be quite severe, even resulting in shock. They commonly cause headache
and can be especially troublesome for asthma patients, urticaria patients, and angioedema
sufferers.
COMMON ALLERGENS
Citrus Fruits
Oranges, lemons, limes, grapefruit, and tangerines can cause eczema and hives, and often,
asthma. They commonly cause canker sores (aphthous stomatitis).
Although citrus fruit allergy does not cause allergy to artificial orange and lemon-lime drinks, if
patients are allergic to citric acid in the fruits then they will also react to tart artificial drinks and
may also react to pineapple.
COMMON ALLERGENS
Tomatoes
This fruit, commonly called a vegetable, can cause hives, eczema, and canker sores. It can also cause
asthma. In addition to its natural form, it can be encountered in soups, pizza, catsup, salads, meat
loaf, and tomato paste or tomato juice.

Wheat and Other Grains

Wheat, rice, barley, oats, millet, and rye are known allergens, with wheat the most common of the
group. Wheat occurs in many dietary products. All common baked goods, cream sauce, macaroni,
noodles, pie crust, cereals, chili, and breaded foods contain wheat.
Reaction to wheat and its related grains can be severe. Asthma and gastrointestinal disturbances are
the most common reactions.
COMMON ALLERGENS
Spices
Of various spices that can cause allergic reaction, cinnamon is generally the most potent. It can
be found in catsup, chewing gum, candy, cookies, cakes, rolls, prepared meats, and pies.
Bay leaf allergy generally occurs as well, since this spice is related to cinnamon. Pumpkin pie
reactions are common owing to their high cinnamon content.
Other spices most frequently mentioned as allergens are black pepper, white pepper, oregano,
the mints, paprika, and cumin.
COMMON ALLERGENS
Artificial Food Colors
Although various artificial food colors have been implicated in such problems as hyperactive
syndrome in children, as allergens the two most common offenders are amaranth (red dye) and
tartrazine (yellow dye).
Amaranth is most often encountered, but reactions to tartrazine tend to be more severe. Food
colors occur in carbonated beverages, some breakfast drinks, bubble gum, flavored ice foods,
gelatin desserts, and such medications as antibiotic syrups.
OTHER FOOD ALLERGENS
Any food is capable of producing an allergic reaction. However, those offenders often mentioned
after the top 10 are pork and beef, onion and garlic, white potatoes, fish, coffee, shrimp,
bananas, and walnuts and pecans.
Vegetables, other than those already mentioned, rarely cause allergic reactions. Fruits that
usually are safe include cranberries, blueberries, figs, cherries, apricots, and plums.
Chicken, turkey, lamb, and rabbit have proven to be the safest meats.
Tea, olives, sugar, and tapioca are also relatively safe foods, although some herbal teas can cause
unique difficulties.
Inspecting Foods to Avoid Allergic
Reactions
Current regulations require that all added ingredients be declared on the label, yet there are a
number of issues that have arisen in connection with undeclared allergens that are not clearly
covered by label regulations.
To protect the consumers, both adults and children, the FDA has asked its food inspectors to pay
attention to the following when inspecting an establishment that manufactures processed food
products.
1. Products that contain one or more allergenic ingredients, but the label does not declare the
ingredient in the ingredient statement.
2. Products that become contaminated with an allergenic ingredient due to the firm’s failure to
exercise adequate control procedures, for example, improper rework practices, allergen
carryover due to use of common equipment and production sequencing, and inadequate
cleaning.
Inspecting Foods to Avoid Allergic
Reactions
3. Products that are contaminated with an allergenic ingredient due to the nature of the product
or the process, for example, use of common equipment in chocolate manufacturing where
interim wet cleaning is not practical and only dry cleaning and product flushing is used.
4. A product containing a flavor ingredient that has an allergenic component, but the label of the
product only declares the flavor, for example, natural flavor. Under current regulations, firms are
not required to declare the individual components of flavors, certain colors, and spices.
However, firms are encouraged to specifically label allergenic components and ingredients that
are in spices, flavors, and colors.
5. Products that contain a processing aid that have an allergenic component, but the label does
not declare it. Processing aids that contain allergenic ingredients are not exempt from ingredient
declaration.
Inspecting Foods to Avoid Allergic
Reactions
FDA believes there is scientific consensus that the following foods can cause serious allergic reactions
in some individuals and account for more than 90% of all food allergies:
• Peanuts
• Soybeans
• Milk
• Eggs
• Fish
• Crustacea (e.g., shrimp)
• Tree nuts
• Wheat
Inspecting Foods to Avoid Allergic
Reactions
Each FDA food inspector is asked to pay special attention to the following:
1. Product development: Determine whether the firm identifies potential sources of allergens
starting in the product development stage.
2. Receiving: Determine whether the firm uses allergenic ingredients and how they are stored.
3. Equipment: Try to inspect the equipment before processing begins and document the
adequacy of clean up.
4. Processing: Determine what control measures, if any, are used by the firm to prevent the
contamination of products that do not contain allergens.
Inspecting Foods to Avoid Allergic
Reactions
The inspection is especially concerned about the labeling that will be checked as follows:
1. Determine if finished product label controls are employed; for example, how are labels
delivered to the filling and/or packaging area?
2. Determine if product labels with similar appearances but different ingredients are controlled
to ensure that the correct label is applied to correct product.
3. Determine if finished product packages are inspected prior to distribution to ensure that an
allergen containing product is labeled properly, or that labels are inspected during production. Is
that inspection documented?
4. Determine if secondary ingredients are incorporated in the final product ingredient
statement, for example, the raw material mayonnaise, which contains eggs, oil, and vinegar.
Inspecting Foods to Avoid Allergic
Reactions
5. Determine if the firm uses a statement such as “This product was processed on machinery
that was used to process products containing (allergen)” or a statement such as “may contain
(allergen)” if the firm uses shared equipment for products that contain and products that do not
contain allergens. Any other such statement? Ask the firm why they believe they have to use the
advisory statement.
6. Determine if the finished product label reflects any advisory statements that were on the raw
material labels, for example, “This product was processed on machinery that was used to
process products containing (allergen).”
7. Determine if the firm has a system to identify finished products made with rework containing
allergenic ingredients. Does the final product label identify the allergens that may have been in
the reworked product?
Food intolerances
Food intolerances are ARFs that result in clinical symptoms but are not caused by an immune
system reaction. They are caused by nonimmunologic mechanisms including toxic,
pharmacologic, gastrointestinal, genetic, metabolic, psychogenic, or idiosyncratic reactions (see
Table 26-2).
Food intolerances are much more common than food allergies and are usually triggered by
small-molecular weight chemical substances and biologically active components of food (Joneja,
2013).
Symptoms caused by food intolerances are often similar to food allergy and include GI
symptoms, cutaneous, respiratory, and neurologic manifestations such as headaches (see Table
26-2).
Clinically, it is important to distinguish food intolerance from immune-mediated food allergy
because food allergies can cause life-threatening anaphylactic reactions, whereas food
intolerances do not.
Carbohydrate Intolerance
Carbohydrate Intolerance
Carbohydrates—sugars, starches, and polysaccharides—are complex in structure and must be
broken down by enzymes for optimal digestion, absorption, and assimilation. Adverse reactions
can occur if there is a deficiency of enzymes responsible for carbohydrate digestion, especially of
disaccharides, such as lactose or sucrose, or if there is malabsorption of the breakdown
products.
Lactose Intolerance
Lactose Intolerance
Intolerance to the disaccharide lactose is the most common ARF, and most cases result from a
genetically influenced reduction of intestinal lactase. It is estimated that up to 75% of the
world’s population has hypolactasia (Bulhoes et al, 2007; Jarvela et al, 2009).
Abdominal bloating and cramping, flatulence, and diarrhea occur usually up to several hours
following lactose ingestion. Because some of the GI symptoms are similar, lactose intolerance is
often confused with allergy to cow’s milk; however, most individuals who are allergic to cow’s
milk also have symptoms in other organ systems, including the respiratory tract, skin, and, in
severe cases, systemic anaphylactic reactions.
Fructose Intolerance and the Inability to
Digest Fructose Polymers (FODMAPs)
Fructose Intolerance and the Inability to Digest Fructose Polymers (FODMAPs)
Fructose intolerance is evidenced by an inability to digest and absorb the monosaccharide fructose,
either from a food containing fructose directly or the disaccharide sucrose (glucose 1 fructose).
Maldigestion and malabsorption of the fructo-, oligo-, di-, and monosaccharides and polyols
(FODMAPs) may also occur.
Humans lack the hydrolase enzymes necessary to break down the bonds in the fructose polymer
chains, so most individuals will develop symptoms if too much of these carbohydrates are consumed
(Joneja, 2013).
Intake of large quantities of FODMAPs will lead to bloating, diarrhea, cramping, and flatulence.
The symptoms appear to be more common in individuals who have an underlying functional GI
disorder, such as irritable bowel syndrome (see Chapter 28 for discussion of FODMAPs and the diet
management, which eliminates excess fructose, fructose polymers, and the sugar alcohols).
Pharmacologic Reactions
Pharmacologic Reactions
An adverse reaction to a food may be the result of a response to a pharmacologically active
component in that food. A wide range of allergy-like symptoms can result from ingestion of
biogenic amines such as histamine and tyramine.
Causes and examples of food
intolerances
Food intolerances are ARFs resulting in clinical symptoms that are not immunologic in
nature. Causes of food intolerances include:

a. Gastrointestinal disorders- which includes enzyme deficiencies and malabsorptive

disorders such as (lactose intolerance and G6PD) and diseases of the involving
digestive system such as cystic fibrosis, gallbladder and pancreatic diseases, and
inflammatory bowel diseases.
b. Inborn errors of metabolism - examples include phenylketonuria or PKU and
galactosemia

c. Psychologic or neurologic reactions

Causes and examples of food
intolerances
d. Reactions to pharmacologic agents in food - includes adverse reactions to foods containing
phenylethylamine (chocolates, aged cheese and wine), tyramine (aged cheeses, brewer's yeast, canned
fish, chicken liver, bananas, eggplant, tomatoes, and raspberries) and histamine and other histamine-
releasing agents (aged cheese, fermented foods, shellfishes, egg whites, chocolates, alcohol, peanuts
etc.)

e. Reactions to food additives - artificial coloring agents (like tartrazine and azo dyes), benzoates,
butylated hydroxyanisol (BHA), burylated hydroxytoluene (BHT), monosodium glutamate (MSG),
nitrates and nitrites and salicylates.

f. Sulfites- in shrimps, avocado, instant potatoes, dried fruits and vegetables, etc.

g. Reactions to microbial contamination or toxins in food - Proteus, Klebsiella, or Escherichia coli

bacteria cause histidine to break down to a histamine
Clinical symptoms of food
intolerances
Food intolerances are more common than food allergies. While food
allergies and intolerances often share the same symptoms, it is
important to note that immune-mediated food allergy can cause life-
threatening anaphylactic reactions, whereas food intolerances do not.
Listed below are the symptoms of food intolerances which may vary
depending on the cause of intolerance.
Bloating and flatulence, Diarrhea and abdominal pain, Anemia,
Malabsorption , Anorexia, Nausea, Elevated levels of phenylalanine,
Mental retardation, Migraine, Hives, itching and eczema and others.
Assessment of ARFs
The diagnosis of ARFs requires identification of the suspected food or food
ingredient, proof that the food causes an adverse response and verification of an
immune or non-immune-mediated response.. It starts with a detailed clinical
history and then followed by appropriate testing procedures.
Immunologic testing includes skin tests and blood tests for serum antibody and
other tests which measure cytokines released by the body's immune system in
response to food antigen exposure. Oral food challenge tests are also used to
detect the suspected food that causes allergic reactions. The test is done with
medical supervision. There are three methods used in food challenge protocols:
Assessment of ARFs
1. Double-blind, placebo-controlled food challenge
(DBPCFC) A food challenge in which neither the patient nor
physician knows the identity of the test food component,
which is usually disguised as a powder in a food known to
be tolerated (such as applesauce) or in a gelatin capsule. The
patient's reaction is compared to his or her reaction to the
placebo, and the patient is monitored in a clinical setting.
Assessment of ARFs
2. Single-blind food challenge A food challenge in which the
patient is blinded to the challenge food's identity, but the
clinician is not. The food or a powder of it is disguised in
another food and reactions are observed and recorded.
Assessment of ARFs
3. Open food challenge A food challenge in which the
patient is knowingly given a serving of the suspect
food and observed for several hours for a reaction.
Management of adverse food reactions
A. Medical- include prescription of anti-histamine and anti- inflammatory
medications with the purpose of alleviating the symptoms of allergic reaction.
Dietary- involves thorough recording of food and symptoms experienced over a
period of 7 to 14 days to carefully analyze the culprit of allergic reaction. Once a
food is suspected to cause clinical symptoms, it will be eliminated in the diet for 4
to 12 weeks (food elimination).This aims at reducing and eliminating the clinical
symptoms and eventually reintroducing the food in minute amounts
(desensitization) to confirm the suspected allergen and monitor symptoms that
may be produced during the process.
Bases of dietary management
1. Essentiality of nutrients - if the nutrients present in the food is vital to the
individual's health
2. Fatality of symptoms - as a rule, if the symptoms are serious, food item is
completely eliminated.
If the allergenic foods do not make up an entire food group, then the regular diet
plan may be used with the omission or restriction of the particular food causing
the adverse reaction. The substitution by other food sources to replace the
nutrient that could be missing in the diet due to omission or restriction may be
needed to prevent development of deficiencies and to assure adequate intakes to
promote optimal nutritional status.