Fueling the gymnast is a big undertaking and is made so much more complex when working with food allergies, intolerances, or other gastrointestinal issues.
There is a lot of misinformation out there on what food allergies or intolerances are or aren’t, and this makes fueling the gymnast that much more confusing.
For some athletes with food allergies, it’s a matter of life or death in terms of preventing exposure to the food allergen.
For others with intolerances, it may be more of a “dose makes the poison” situation.
As a clinically trained pediatric dietitian, I spent several years working with patients and families of children with multiple food allergies or intolerances, including really severe conditions like Food Protein Induced Enterocolitis (FPIES) and Eosinophilic Esophagitis (EOE). These conditions are no joke and can result in poor growth and development if the diet is not properly formulated to meet nutritional needs in light of what has to be eliminated.
If you’re a parent, coach, or gymnast, you need to know the differences between food allergies and intolerances, and what major nutrients you might be missing out on that can affect the health and longevity of the athlete.
What are food allergies?
The prevalence of food allergies in the United States has increased, and is now estimated to affect 6-8% of children. The “top 8” allegens include milk, soy, peanuts, treenuts, wheat, egg, fish, and shellfish.
A food allergy is an abnormal immune-mediated reaction to ingested food, resulting in clinical symptoms. Food allergies can be classified by their immune mechanism:
- IgE mediated
- Non-IgE mediated
- Mixed IgE and non-IgE mediated
Cross-Reactivity of Foods
Cross-reactivity means clinically allergic to similar proteins present in related foods. For example, in individuals allergic to:
- Cow’s milk: ~90% will be allergic to goat’s milk
- Cashew: most will be allergic to pistachio
- Fish: ~75% will be allergic to other fish
- Prawn: most will be allergic to other crustaceans (e.g. crab, lobster)
- Peanut: ~5% are allergic to another legume (e.g. soy)
- Oral allergy syndrome: allergic to similar proteins in pollen and some fruit/vegetables
IgE mediated food allergy
Common food allergens in children include cow’s milk, egg, peanut, tree nut, wheat, soy, sesame, fish and shellfish. Children with peanut, tree nut, sesame, fish and shellfish allergy usually do not outgrow these allergies. However, cow’s milk, egg, soy and wheat allergy commonly resolve, with a majority (~80-85%) of children in population-based studies outgrowing their allergy to cow’s milk or egg by age 3-5 years.
- Reactions occur when allergens bind to Immunoglobulin E (IgE) antibodies bound to mast cells, resulting in the release of histamine and other inflammatory mediators.
- Symptoms are usually of rapid onset (<30 minutes in children, usually <2 hours in adults).
- Diagnostic tests (e.g. skin prick and blood tests) are usually positive.
- Signs of mild or moderate allergic reactions:
- Swelling of lips, face, eyes
- Hives or welts
- Tingling mouth
- Abdominal pain, vomiting
- Eczema or rashes
Anaphylaxis is a severe allergic reaction which is defined by any one of the following signs: – Difficult/noisy breathing.
- Swelling of tongue
- Swelling/tightness of throat
- Difficulty talking and/or hoarse voice
- Wheezing or persistent cough
- Persistent dizziness or collapse
- Pale and floppy (young children)
The treatment of severe food reactions can include the need for epinephrine (an EpiPen) and medical attention. If not treated in time, death can occur.
Non-IgE Mediated Food Allergy
Non-IgE mediated food allergy occurs when the ingested food protein causes an immune response resulting in delayed inflammation, normally in the skin or gastrointestinal tract.
- Symptoms usually occur 2-24 hours after ingestion of the food protein.
- Diagnostic tests are usually negative
- Symptoms include delayed eczema; delayed vomiting and diarrhea; loose, frequent bowel actions; blood or mucus in stools; irritability and unsettledness in infants. Specific conditions include food protein-induced enterocolitis syndrome (FPIES), proctocolitis and food protein induced enteropathy.
This type of food allergy doesn’t usually cause anaphylaxis.
Mixed IgE, Non-IgE Mediated Food Allergy
- Symptoms are caused by one or both mechanisms described above
- Conditions include eosinophilic esophagitis and eczema
Food Allergy Testing
Allergy tests are not stand-alone diagnostic tools. Diagnosis of allergy is based on a combination of:
- Clinical history
- Tests to identify IgE sensitization to an allergen. These should be undertaken and interpreted by a clinical immunology/allergy specialist
- Skin Prick Testing (SPT). This detects the presence of allergen reactive IgE bound to skin mast cells. SPT results must be performed by trained medical professionals and interpreted by a clinical immunology/allergy specialist.
- Serum allergen specific IgE (ssIgE) a blood test formerly known as RAST. This measures allergen reactive IgE in the blood.
- Medically supervised oral food allergen challenge (as required). Patch testing is not used to confirm IgE mediated food allergy.
It is important to note that many people with positive allergy tests do not have clinical allergy and suspected allergy should always be confirmed by a clinical immunology/allergy specialist.
Unproven and inappropriate methods that claim to test for allergy or intolerances:
- Includes IgG testing to foods (like most at-home food sensitivity tests or tests that alternative medicine practitioners or nutritionists can order themselves), cytotoxic food testing, kinesiology, Vega testing, electrodermal testing, pulse testing, reflexology and hair analysis.
- Are not scientifically validated and may lead to unnecessary, costly and (in the case of some changes in diet) dangerous avoidance strategies.
Treatment for Food Allergies
Treatment often includes strict elimination of the offending food. This is where the gymnast’s overall nutrient intake can be jeopardized, as many of the major allergens are also major sources of essential nutrients in the diet like Calcium, Vitamin D, Iron, B vitamins (B6, B12), Folate, and others.
Poor growth and inadequate nutrient intake by food allergic children have been suggested in previous studies, particularly for children avoiding milk.
What are food intolerances?
Food allergies are different from food intolerances, in that food intolerance can cause similar reactions but are not due to an immune response. These are mediated by the digestion system and are not life threatening.
While food allergy and food intolerance are commonly confused (since symptoms of food intolerance occasionally resemble those of food allergy), the following important points should be noted:
- Food intolerance does not involve the immune system and does not result from IgE mediated reactions, nor does it cause anaphylaxis.
- The exact mechanism by which some food intolerances occur is not always clear.
- There is no reliable skin or blood test to diagnose food intolerance
- Diagnosis of food allergy and risk of anaphylaxis should always be medically confirmed.
- In some patients, dietary elimination and challenge may assist diagnosis
The term “food sensitivity” and “intolerance” are often used interchangeably but mean the same thing. These “sensitives” are often blamed for symptoms like fatigue, exhaustion, bloating, acne, hormonal issues (PCOS, amenorrhea), migraines, anxiety, irritable bowel syndrome (IBS), muscle soreness, constipation, and more.
Some food intolerances come from metabolic origin due to an enzyme deficiency, like lactose intolerance. Other pharmacological reactions to food components like caffeine, monosodium glutamate (MSG) and other naturally occurring food chemical (salicylates, amines) can cause reactions.
Misdiagnosis of Food Allergies & Intolerances
The medical community (conventional and alternative) can be quite overzealous at times in terms of prescribing dietary elimination due to overdiagnosis of food allergy or intolerance. The “elimination diet” is one that should not be prescribed to anyone, much less a high-level athletes, without great thought and clinical evidence for doing so. Any sort of dietary elimination can be very disrupting, increase psychological stress(which can worsen GI symptoms) and is difficult to execute especially in children and adolescents.
There are many published case reports (and anecdotal reports amongst professionals) of individuals who were misdiagnosed with food allergies or intolerances that were actually related to serious medical issues like eating disorders, cancer, etc. Even non-body image related eating disorders like ARFID (Avoidant Restrictive Food Intake Disorder) can be exacerbated if not prompted by being told to eliminate multiple foods to “heal” themselves
Causes of GI issues that aren’t related to food
–Pelvic Floor Dysfunction (yes, even young gymnasts can struggle with this, much more common than you may think)
–Underfueling (may or may not be related to disorder eating or an eating disorder)
Nutritional Barriers to Fueling the Gymnast with Food Allergies
I have written about these in multiple other blog posts (linked below) as they are essential for the high level gymnast to reach her potential in and out of the gym.
–Inadequate energy intake (multiple food allergies, protein sources): For gymnast with multiple food allergies, it can be hard to ensure adequate overall energy intake. Paying attention to meal/snack frequency and composition can help (along with working with a pediatric/adolescent dietitian specialized in food allergy).
–Inadequate dietary variety : a lot of gymnasts with multiple food allergies not only struggle to eat enough, but often get stuck in a “rut” with the same mix of safe foods. This can be particularly challenging when it comes to “satisfaction” and it’s not uncommon to have binging or overeating when the diet has to be so restricted. Working with a dietitian to help liberalize the diet as best as possible can be a huge help with compliance and quality of life.
–Inadequate Calcium/Vitamin D (avoidance of milk or milk and soy): These days there are a lot of plant-milk alternatives with comparable calcium and vitamin D to cow’s milk, but very few have the same protein (and no plant protein is as of high quality as animal protein, which is important for digestibility and muscle protein synthesis).
–Inadequate B12 (milk, egg, fish, meat): Known as an “energy vitamin”, B12 is a major nutrient found in animal proteins. Vegans are often deficient in B12 which needs to be supplemented orally of via intramuscular injection.
–Inadequate B6 (soy, fish): Another “energy vitamin” that’s important for the gymnast (also related to potential PMS symptom alleviated). Avocado, banana, and fortified grains are good plant-based sources.
–Inadequate Folate (soy, egg, wheat): The good news is that many plant sources like beans, spinach, orange juice, and asparagus are also great sources of folate.
The Value of working with a Registered Dietitian Nutritionist
If your gymnast has food allergies or intolerances, I’d advise you regularly check in with the pediatrician to monitor growth and development. For high level gymnasts, especially those with multiple food allergies, it’s essential to check in with a registered dietitian nutritionist who’s trained in food allergies or intolerances. They can help you plan proper meals and snacks that ensure your gymnast is getting the essential nutrients she needs to grow, develop, and reach her genetic potential in terms of performance. Feel free to reach out if you are looking to help your gymnast meet her nutritional needs and reach her highest potential.