August 2010 Issue

Get Certified — Provide a Valuable Service by Adding Allergy Testing to Your Practice
By Maura Keller
Today’s Dietitian
Vol. 12 No. 8 P. 18

Dietitians, especially those who own private practices, are always looking for new opportunities to grow their business. Today’s RDs offer myriad diet-related services to help improve their clients’ overall well-being, and one growing service area is diagnostic testing for food allergies and intolerances.

“As nutrition experts, dietitians focus on many aspects of a person’s health and look for creative ways to find out what causes the troublesome symptoms patients experience,” says Debra Indorato, RD, LDN, CLT, of Approach Nutrition Food Allergy Management. “People are reading and hearing about food allergies in the media. They want to know if they have a problem with certain foods. Dietitians who have added diagnostic testing to the services they offer provide a valuable service to their patients.”

As Joy Supplee, MS, RD, CD, CLT, of Custom Fit Nutrition explains, an increasing number of people seem to be having difficulty with certain foods causing various symptoms. “Since menu planning and diet recommendations are an RD’s specialty, it makes sense that finding out which foods are causing problems for any given client is part of more complete care for that client,” Supplee says. “Testing for celiac disease is becoming more well known, as is testing for other food difficulties such as sensitivities or those involving other immune pathways besides the typical IgE [immunoglobulin E] pathway attributed to a true ‘allergy.’”

Supplee has taken specialized training through Signet Diagnostic Corp to become certified in the Lifestyle Eating and Performance (LEAP) dietary protocol. She also administers the Mediator Release Test (MRT) blood testing as part of that training. She often works in tandem with a client’s primary care provider to order the test and then administers the dietary counseling accordingly.

Not surprisingly, there is a huge void between receiving the results of allergy testing and a patient’s next trip to the supermarket. When RD Lori Langer’s son had IgE-mediated/type 1 food allergy testing done 13 years ago, she left the allergist’s office with the knowledge that he was allergic to six of the top eight most prevalent food allergens.

“The trip to the supermarket that followed took hours and was overwhelming, even for a dietitian,” says Langer, RD, MEd, CLT, LDN. “Those of us who care for those with food allergies know that when a person is allergic to a single item, in reality, one must check ingredient labels for possibly 100 different ingredients that may be derived from that one food. Now multiply that by several allergens and the task of grocery shopping for an allergic individual can be overwhelming, not to mention cooking the food.

“A very skilled, trained professional needs to provide the allergic individual with a bridge of information—food avoidance and nutrient replacement handouts, for starters,” she continues. “A registered dietitian, with an extensive knowledge of food allergies, is the logical choice. This is hugely important because it can mean the difference between life and death for one with an anaphylactic allergy.”

Training Required
A few companies offer programs for dietitians, the most popular being the LEAP program offered by Signet Diagnostic as a self-study program for dietitians to become certified. The didactic part of the program is on CD. Once they complete the home-study part, students need to pass a comprehensive exam to become LEAP certified.

Once certified, these dietitians can provide their patients with the opportunity for food-sensitivity testing. The test is the MRT, which is for non–IgE-mediated reactions that are delayed and immune based. “It is primarily used for patients who have irritable bowel [syndrome (IBS)], fibromyalgia, and migraines, although patients with other symptoms suspected to be triggered by foods may consider having the test done,” Indorato says.

Langer became a certified LEAP therapist last fall and helps guide her patients through a customized diet plan to meet their individual needs.

“MRT is vastly important to my practice because there is an incredibly high number of patients who suspect that food makes them ill and yet nothing turns up causative on their [IgE-mediated] allergy tests, such as RAST [radioallergosorbant test] and scratch tests,” she says. “Chances are they are suffering from food sensitivities. Only MRT can quantitatively and qualitatively (with a 93% overall accuracy) pinpoint food-sensitivity triggers. It is not uncommon for a patient to have dozens of food and chemical sensitivities and, in such cases, it is nearly impossible to detect a pattern of symptoms triggered by ingestion, even using very restrictive elimination diets. Without MRT, it’s like working in the dark.”

As Diana Bright, MS, RD, CCN, CLT, explains, another diagnostic test RDs and physicians use is the Enzyme-Linked Immunosorbent Assay, commonly known as ELISA, which tends to focus on a specific immune pathway such as IgG/IgE.

“ELISA quantifies how much IgG you are producing to a specific food, with the assumption that high levels of IgG are only a bad thing,” Bright says. “There is a specific type of immune reaction called type 3 hypersensitivity that can involve IgG or another antibody called IgM. When IgG is involved in triggering mediator release, this testing will be very helpful.”

There are three serious limitations of IgG testing, as follows:

• High levels of IgG can be either good (suppressing an immune response) or bad (causing an immune response). “But you cannot tell which is good IgG or which is bad IgG through this testing,” Bright says. “So just because you have a high level, [that] may actually be good, not bad.”

• IgG only plays a minor role in IBS, migraines, and fibromyalgia. Instead, research shows that type 4 hypersensitivity is the primary type of reaction. Type 4 hypersensitivity doesn’t involve IgG or any other antibodies.

• IgG testing cannot identify reactions to chemicals such as food additives. “It’s clearly documented that food chemicals play a very important role in provoking symptoms in many conditions,” Bright says. “If you cannot identify these reactions, you could very well be missing very important information that can impact your health.”

As Supplee explains, many physicians use ELISA in their practices because it tends to be very inexpensive. “However, I believe these tests are less comprehensive than the MRT and, as such, provide an incomplete picture,” she says. “I’ve had several patients come to me after having these tests, feeling that the test didn’t show everything or, in several cases, showed nothing at all, whereas the MRT will pick up more reactions. The MRT is not limited to these pathways and picks up more reactions such as those involving T cells, which studies show are implicated in delayed hypersensitivity reactions.”

What the Future Holds
When Jan Patenaude, RD, CLT, a consultant and director of medical nutrition at Signet Diagnostic, started providing MRT and LEAP protocols, the testing was still quite new, but she quickly realized the results of her efforts.

“I saw amazing results in clients—clients who had ‘been there, done that’ regarding physicians, meds, diet changes, diet consults; clients who had nearly given up hope [of] ever finding an answer to their migraines or IBS or arthritis pain or fibromyalgia,” she says. Patenaude started spreading the word, since it was the most exciting, rewarding, challenging, and interesting work she’d ever done as an RD.

“It’s very rewarding to help people get well,” she says, “especially if getting them well is life changing or if we get them off meds with horrible side effects. Or if we get them pain free when they were dealing with chronic pain before.”

And Patenaude is not alone. Supplee believes that the more RDs understand food reactions for their clients, whether allergy, sensitivity, or intolerance, the better care they will provide.

“Why recommend chicken breast to a client who actually experiences symptoms after eating chicken breast but can’t quite put their finger on what the culprit is?” Supplee asks. “Or, as in the case of the prescribing physician, why prescribe an antidepressant that contains cornstarch to someone sensitive to corn? I have had several clients who ended up needing to change their medications after finding out they were sensitive to some of the inactive ingredients/fillers they contain. These examples of sensitivities can be very difficult, if not impossible, to determine without the use of a test such as the MRT. Ideally, the physician and RD should be working together to provide the best team approach for patient care. I believe this area is going to continue to grow.”

Indorato agrees: “Initially dietitians were skeptical, but as more dietitians are getting involved in food allergy and sensitivity, sharing successes of clients through results and testimonials, more dietitians are getting on the bandwagon,” she says. “Many dietitians who have health concerns of their own have gotten tested, followed the diet, and felt the benefits. RDs should incorporate testing into their practice, as it is a way to grow their practice and offer a service their patients want. If RDs don’t do it, other health practitioners will.”

— Maura Keller is a Minneapolis-based writer and editor.