#ULOG 1: "Will you put your patient at risk?" The question my professor asked me boggled my mind

This afternoon, we had a presentation on a subject called Medical Nutrition Therapy I. The exercise was about adverse food reactions: food allergies and food intolerances. I was the assigned dietitian for our group, so I was in charge of the oral report. Part of the exercise was outlining the steps in determining the food allergen among the food items eaten by the hypothetical case patient at a cocktail party. The presentation was brief and simple - we just had to present the flow of analysis in the determination and the recommended treatment.

I was the second reporter. I said a short prayer in my mind, remembering that everything will turn out fine. Our professor was asking the first reporter a lot of questions about the exact procedure of administering an elimination diet, which is an eating plan wherein certain foods suspected to trigger a food allergy would be avoided for about three weeks. I felt nervous because our answers were not the same, and the professor did not seem to be pleased.

It was not a simple case; even though the foods the case patient ate a few hours ago were listed, it should still be noted that the offending substance could be in the foods she had eaten earlier in the day or even within 48 hours ago. Thus, more foods have to be temporarily excluded from the diet. This was the critical point for the first reporter.

It was finally my turn to speak in front. I began by explaining that the exercise assumed that the cause of the symptoms was a food allergy and not food intolerance. This was to justify elimination diet as the first step in allergen determination. Diagnosis of an adverse food reaction would be more complicated, as more tests need to be done to confirm that it was indeed an allergic reaction, that is immunoglobulin E (IgE)-mediated; simply put, the body identified a rather harmless substance as a foreign invader and commenced an immune response to get rid of it.

The professor asked a lot of questions about that part, which heightened my nervousness. I knew what I was going to say, but questions like that could catch you off guard. I then proceeded to the next step, which was a single-blind, placebo-controlled food challenge. I then explained that the patient is unaware when the food allergen is being given and that an additional food, which would not elicit an allergic reaction, is mixed with the other foods.

I explained that the food challenge was meant to test which of the eliminated food items is/are causing the allergic reactions. One at a time, each suspect food would be given to the patient starting with a small amount, until a reaction is observed. The test is straightforward, once the patient develops symptoms after eating a certain food item, then that food is confirmed to be the allergen. I mentioned that these tests should be done at a clinic with an attending physician and ready-to-be-administered emergency supplies to stop the symptoms since these can range from mild to life-threatening, as in anaphylaxis, a whole-body reaction that includes difficulty breathing and an extremely low blood pressure.

Finally, I arrived at the last part of my report - the recommended treatment.

I concluded with a statement that the treatment I would recommend my patient would be an elimination diet. It was assumed in the exercise that shrimp was the food allergen, hence, unlike other food allergies, removing it from the diet would not cause a substantial change in nutritional quality. After all, there are many alternative foods that could supply the nutrients in shrimp. It also does not lurk in other unsuspected food items, which means that there is a very small chance that the patient would accidentally eat it without knowing. Other foods may contain peanuts, a major food allergen, due to the shared processing equipment. This is even indicated in products' food labels.

I argued that desensitization or allergy immunotherapy is unnecessary for the case patient and that it is ideal for persons with multiple and more severe allergies. Basically, the idea behind this is that, the patient will be given a very small amount of the allergen, gradually increasing it in amount until the patient is able to tolerate it. However, there are inherent risks to it.

In cases of a patient with severe allergies, introducing even small amounts can induce a reaction that can be life-threatening. I was aware of this risk. Multiple studies have shown success with this treatment, and they find that this can benefit those patients the most. It has been a concern that these patients experience difficulties in careful avoidance of foods; in some instances, an accidental ingestion due to contamination with the allergen or being uninformed of the food item's ingredients led to severe reactions. Thus, such a treatment may help them overcome the food allergen. Studies recognize that this treatment is not as accepted as the total avoidance of allergens, but it can be more established in the future.

Our professor's facial reaction changed; she looked surprised as I was saying those things. She then asked me,

"Will you put your patient at risk?"

I was stunned. I never thought of putting my patient at risk. I then answered that the decision would be up to the patient and that risks and benefits have to be weighed. The same risk is present during diagnosis, that is during the food challenge. There is also an ever-present risk of accidental ingestion; for example, milk and peanuts can be hidden in other foods without the patient knowing. Food labels do not always completely indicate all food items mixed with other ingredients. Thus, benefits could outweigh the risks, if we look at the long term. The patient's quality of life is also important, which is why certain risks need to be taken.

As a nutrition student, I want to learn everything I could to give my future patients and clients the best prescriptions and recommendations. This exercise taught me a lot, even though I was almost humiliated as I returned to my seat. After all, mistakes are a part of life. God made us that way so that we will learn to be humble and be focused on what needs to be improved in us - not boasting of what we are good at.

Thanks be to God for surviving the last exercise for this subject. The end of the semester is near, and the remaining requirements for this laboratory component are the case study, second theoretical exam, and a practical exam. I don't know how I was able to come this far; all I know is that I would not be able to make it without my God.

Romans 8:28
And we know that all things work together for good to them that love God, to them who are the called according to his purpose.