Memorandum by the British Society for
Ecological Medicine
1. DEFINING THE
PROBLEM
1.1 What is allergy? What is the difference
between allergy and intolerance?
Allergy is an acquired sensitivity to environmental
factors or foods, provoking adverse effects. In the immediate
past, the term has been limited to reactions whose mechanisms
have been shown to depend on the "allergy" antibody
IgE, and other sensitivities have been labeled intolerance. There
is increasing dissatisfaction with this limitation because:
— The original use of the term was
much broader.
— The so-called intolerances are heterogeneous
and need different managements since they include intolerances
with an idiosyncratic biochemical basis as well as sensitivities
which behave like allergies.
— In clinical practice these allergy-like
intolerances contribute to the aetiology of a wide variety of
chronic illnesses including migraine, IBS, hyperactivity, asthma,
eczema, arthritis, chronic fatigue, rhinitis, conjunctivitis,
failure to thrive and other conditions which are "not medically
explained".
— Many of these chronic conditions
respond well to allergy management: symptoms are relieved, and
subsequently prevented, when the provoking trigger(s) is identified
and avoided (Addendum A). [not printed]
IgE-mediated allergic reactions mainly include
local reactions in and under the skin, of the airways, and of
the gut and the severe general reaction, anaphylaxis. They are
mainly provoked by pollens, moulds, animal antigens, house dust
mites, insect venoms, a few foods and a few industrial chemicals.
Non-IgE mediated reactions may also be provoked by these allergens
but also by others including almost any food and a large number
of chemicals: they may produce similar symptoms, but also
chronic or recurrent symptoms involving virtually any body system.
1.2 What is and what is not known about the
origins and progression of allergic disease?
The increase in the prevalence of allergy over
the last 50 years has been too rapid to be attributed to changes
in the gene pool, and must be some sort of environmental effect.
However, the increase in the pollenoses (hayfever etc) has not
correlated with an increase in airborne pollen, pointing to some
non-specific effect. Historically allergies started to increase
after the start of the industrial revolution which occurred at
different times in different countries. Within the UK, increases
in pollenoses have correlated with increases in fine particulate
air pollution and with the increasing manufacture of and exposure
to chemical pollutants. However the causal significance of this
link has not been proven. Other evidence suggests that childhood
infections may be protective.
1.3 Why is the incidence of allergy and allergic
diseases rising? Why does the UK in particular have such high
prevalence of allergy?
(a) The rate of increase in allergies is
extremely worrying. If the link in 1.2 is correct, the continuing
increase in the manufacture of and use of chemicals will be one
factor, particularly in the UK which has a high population density
and inadequate monitoring of fine particulate air pollution: pollution
with relatively harmless larger particulates (PMios) has fallen
but pollution with the much more harmful ultra-fine particulates
has increased: these adsorb chemical pollutants and carry them
into the blood stream. Increased release of synthetic chemicals
within buildings from fabrics and DIY, and decreased indoor ventilation
may also be a factor.
(b) The UK has recorded inadequate levels
of intake of several of the vitamins and minerals required for
optimum function of the immune system: deficiencies in the foetus,
infant and child may well contribute to the high rate of allergies.
Disturbingly high levels of pollutants have been found in the
human body, even in neonates: essential nutrients are required
for the metabolism and excretion of chemical pollutants.
1.4 What gaps exist in establishing the overall
disease burden for all types of allergy and what are the barriers
to filling these gaps?
(a) The first gap is the inadequate training
of most GPs in allergy. The second gap is the thoroughly inadequate
supply of allergists of any kind all over the UK so that most
patients with allergies do not have a specialist diagnosis. The
third is the fact that most non-IgE-mediated allergies are not
recognized as such.
(b) One of the main barriers lies in the
poor training in allergies at both undergraduate and postgraduate
level: resulting in many doctors wrongly thinking they know all
they need to know about allergies and others being frightened
of them, trying to have as little to do with them as possible.
The other is the very poor recognition of the nature of non-IgE
mediated allergies, even though they respond well to allergy management.
1.5 In addition to the impact on the health
service, what is the overall socio-economic impact of allergic
diseases (for example, absence from work and schools)?
(a) Allergies used to be rare in childhood:
everyone now knows a family with one or more allergic children,
and the strain that this puts on them and on the schools. In contaminated
neighbourhoods some schools keep a separate room for the pupils'
inhalers.
(b) There have been marked increases in the
prevalence of chronic illness in general in the last few decades
and particularly of rhinitis, asthma, migraine, IBS and of "medically-unexplained
symptoms".
2. TREATMENT
AND MANAGEMENT
2.1 What is the effect of current treatments
on the natural history of allergic disease?
(a) Most patients with allergies are currently
treated either with anti-allergy drugs, steroids and other anti-inflammatory
drugs, or pain killers, or with specific drugs to moderate the
symptoms (eg drugs for bronchospasm). Careful management of the
drug regimes helps control the symptoms (for instance in asthma)
but does not help (and may worsen) the natural history.
(b) The natural history of allergies seems
to be that some children grow out of their allergies naturally
(although they may develop other allergies later in life), but
this process is speeded up by avoidance: if trigger foods are
avoided they may be tolerated after six months or a year. This
may also happen in adults, where onset of allergies usually follows
some form of insult and the trigger substance is often a favourite,
and frequently-eaten food." Continued exposure causing symptoms
tends to worsen the allergic state and leads to sensitivity to
additional foods or environmental pollutants.
(c) Allergic patients tend to be deficient
in several of the vitamins and minerals necessary for optimum
function of the immune system: correcting such deficiencies seems
to improve their general health and lessen their hyperactivity.
Deficiencies in parents before conception and/or of the mother
during pregnancy and lactation lead to poor development of the
foetus/infant: the evidence suggests that this also affects the
immune system, and that it can be prevented by correcting the
deficiencies before conception or during early pregnancy.
(d) Specific desensitisation therapy is used
in mainstream medicine to protect mainly against venomanaphylaxis:
this method is risky and its use is therefore confined to specialist
centres.
(e) Low dose specific desensitisation therapy
is used by non-mainstream allergists to protect against pollens,
moulds etc and against food allergy of both kinds: these methods
use extremely low doses of allergens and are virtually risk-free.
These treatments allow most patients to tolerate moderate exposures
to the specific trigger(s) covered and some patients, but not
all, become less sensitive overall in time. These methods are
supported both by randomized trials and by audit of groups of
patients most of whom had had symptoms for many years before allergy
treatment.
2.2 What is the evidence-base for pharmacological
and non pharmacological management strategies?
(a) For allergies, pharmacological management
strategies are largely palliative, aiming to control the symptoms
not the disease: the evidence-base for this is in standard medical
practice. They are largely ineffective in combating the general
fatigue and lethargy which accompany allergic reactions.
(b) The so-called environmental approach
aims to identify the triggers which provoke the symptoms, so that
they can be avoided, or the patient protected (at least partially)
using low dose desensitisation. The evidence-base for non-pharmacological
management strategies is detailed in the book Environmental Medicine
in Clinical Practice. Anthony HM et al. which can be obtained
from the BSEM office. The evidence includes:
— double blind studies of the management
of food allergy in both children and adults with a wide variety
of chronic illnesses from asthma to arthritis;
— double blind studies of low dose
desensitisation methods, mainly in rhinitis and food allergy;
— long term follow-up audit studies
of severely-affected patients, half of whom had suffered previously
for 10 years or more, and had been referred to a number of different
consultants (11 in one case) without relief;
— published case studies;
— the daily experience of doctors
using these methods where it is not uncommon for patients to say
that after all they had been through, they would not have believed
that it was possible to feel so well.
2.3 Is the level of UK research into allergy
and allergic disease adequate?
No, it is not adequate. This is partly because
of the individually-specific nature of allergies which does not
readily fit into the standard randomized double blind format.
Experiments can only be performed studying the allergens to which
each patient is sensitive, and the symptoms provoked in each individual
patient, and must be done during a window of opportunity unaffected
by previous exposure. There is little or no publicly-funded research
into non-IgE-mediated allergy, although there is considerable
evidence that environmental management would reduce the burden
of chronic ill-health with very large savings for the NHS.
2.4 What are the most promising areas of research
into preventing or treating allergy?
(a) More accurate figures for the prevalence
of allergies could be obtained by a large study based in general
practice if this was designed to identify all the patients with
any of the chronic or recurrent conditions which have been reported
to respond to any type of allergy management, with randomized
matched subsamples of the patients referred for diagnosis and
treatment to mainstream allergists or other consultants as appropriate,
and to allergists using environmental methods.
(b) It would be possible to test the theory
that correction of deficiencies of essential nutrients during
pregnancy (or preferably before conception) would reduce the incidence
of childhood allergy. A study could link investigation of key
nutritional factors during pregnancy using objective tests, with
the well-being of the infant on delivery and the occurrence of
allergies and other conditions in childhood, in two groups in
one of which deficiencies would be corrected and in the other,
not. Ideally this could be controlled by groups randomly assigned
to standard supplementation as currently recommended or to supplementation
with a wider range of essential nutrients.
(c) Cost benefit studies of environmental
methods in several chronic illnesses, such as hyperactivity and
serous otitis media in children, and irritable bowel syndrome,
asthma, migraine and chronic fatigue syndrome in adults.
3. GOVERNMENT
POLICIES
3.1 How effective have existing Government
policy and advice been in addressing the rise in allergies?
We welcome the slight expansion of consultant
training of allergists, most of which is concerned with IgE—mediated
allergy but this remains totally inadequate.
3.2 How is current knowledge about the causes
and management of allergic disease shared within Government?
As far as we are aware the DoH adheres to the
general, circumscribed view of allergy. Some years ago MAAF funded
a study of food intolerance which ignored important aspects of
the natural history of the condition and resulted in useless and
misleading results. It would be very helpful if the DoH were to
fund appropriate studies large enough to establish the clinical
value of management based on the wider conception of allergy.
(a) Do housing policy and regulations
governing the indoor environment pay enough attention to allergy?
There has been co-operation on asthma and housing,
but room for more. Encouraging the elimination of draughts helps
save energy and improves heat retention but it also increases
the retention of chemical pollutants which probably plays a part
in increasing allergies. Government should be making more effort
to reduce the volatile organic compounds released from cleaning
compounds and fabrics and encouraging the use of borax as a fire
retardant.
3.3 How effectively are food policy and food
labeling regulations responding to the rise in food allergies?
Food labeling is improving but incentives should
be given to manufacturers to establish separate production lines
for peanuts so that peanut sensitive patients are not unnecessarily
restricted.
4. PATIENT AND
CONSUMER ISSUES
4.1 What impact do allergies have on the quality
of life of those experiencing allergic disease and their families?
The effect of allergies varies from minor to
devastating. Severe peanut allergy and hyperactivity and asthma
all dominate the lives of the families with sufferers and commonly
lead to relationship breakdown. Many adults with severe allergy
problems are unable to work, either because they are too ill or
because they cannot find work in an environment they can tolerate.
Their position is made worse by the fact that their condition
is not widely understood and they are often treated as if their
illness is imaginary, and denied benefits.
4.2 What can be done to better educate the
public and to improve the quality of information that is available
to patients and undiagnosed sufferers?
(a) The first group to educate is the GPs.
The pharmaceutical companies spend a lot of money teaching GPs
(and other doctors) about drugs, often in lavish surroundings,
or with trips abroad. There is no equivalent source of funding
for allergy and environmental and nutritional methods of practice
and doctors have to pay for their own tuition (which is arranged
by this Society) except for the occasional lectures invited by
postgraduate deans etc. Some GPs actually complain to the GMC
when ecologically-minded doctors get their patients better when
the GP had previously failed.
(b) Although many sufferers are unaware of
how they could be helped, there is currently less scope for educating
the public, partly because they are in general ahead of the doctors
and partly because there are so few allergists and ecologically-minded
doctors at present that educating the public would be counter
productive.
(c) The most pressing need is to increase
the numbers of allergists, and particularly ecologically-minded
allergists (such as members of this society), throughout the country.
Allergists have traditionally not been widely ecologically-minded,
although this is changing. Most ecologically-minded doctors are
practicing privately because there are no NHS jobs for them, except
for a few who manage to combine this sort of practice with NHS
general practice. Few of the private doctors in this field make
a good living, and their finances are now being hit by the requirements
of the Health Care Commission, and will be in the future by the
GMC's revalidation requirements. There is a serious risk that
they will give up the struggle to practice in a way that they
know is much more effective than the standard pharmaco-therapy.
4.3 Are current regulatory arrangements, for
example, those governing private clinics offering diagnostic and
therapeutic services and the sale of over the counter allergy
tests, satisfactory?
(a) No. Private doctors practising ecological
medicine need to be relieved of some of the requirements which
are appropriate for large organisations but not for one or two
doctors offering a much needed service.
(b) An allergy service needs to be headed
by a doctor with postgraduate training covering all aspects of
allergy (such as that provided by this Society), although properly-trained
nurses and dietitians can make valuable contributions. Currently
doctors are much more highly regulated than complementary practitioners.
When complementary therapy organisations were asked what they
did, none of them claimed to practice allergy, but many of their
practitioners are known to identify trigger substances and advise
about diets etc which amounts to practicing allergy. It is unsatisfactory,
and occasionally potentially risky for such people to practice
like this without adequate training and without equipment to manage
any possible emergency.
(c) There is insufficient testing and regulation
of OTC tests.
October 2006
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