In Fall 2009, Massachusetts General Hospital (MGH) established a comprehensive Center for the Treatment and Study of Food Allergy and Food-Related Disorders (the "Food Allergy Center") to provide state-of-the-art care while investigating the mysteries that underlie these inadequately understood and as yet incurable diseases. By dovetailing a multi-specialty collaborative approach to care with research and training, the center's physicians expertly diagnose and treat children and adults suffering from IgE-mediated food allergies as well as food-induced gastrointestinal immune disorders.
The Food Allergy Center has been launched to leverage emerging clinical and research opportunities that provide fresh hope for patients and families and work with them to advance the effort to find effective therapy. Created in partnership with several pediatric and adult specialties at the MGH, the Food Allergy Center's mission is to recruit key faculty and staff; pilot innovative research studies; enhance patient, family and professional education programs; support advanced training in food allergy research and build a clinical research database and specimen bank to facilitate translational research.
A Collaborative, Collegial Approach to Care From Infancy through Adulthood
Approximately 6 to 8 percent of all young children and 4 percent of all adults in the U.S. suffer from food allergies (2), statistics that translate into reduced quality of daily life for approximately 1 in 20 Americans and their families. Common food allergens include milk, eggs, peanuts, tree nuts (e.g. walnuts, cashews) shellfish, soy and wheat, but IgE sensitization can occur to a very wide range of dietary proteins. Millions more Americans are affected by other disorders also induced by an aberrant immune response to certain foods.
The food allergy center focuses on the entire spectrum of these diseases including:
- IgE-mediated food allergy is the most common in both children and adults and places many patients at risk for potentially severe immediate hypersensitivity reactions including anaphylaxis. It also has significant psychological, social and sometimes nutritional co-morbidities that are often underestimated and inadequately addressed. Furthermore, a large number of individuals are misdiagnosed by identification of food-specific IgE without confirmation of clinical reactivity and, therefore, needlessly avoid foods, sometimes to the detriment of their nutrition. Currently, treatment is limited to prevention and treatment of anaphylaxis, but there are several newly emerging therapies that require additional clinical trials.
- Eosinophilic gastrointestinal diseases (EGID), a group of eosinophilic inflammatory diseases involving the upper GI tract that in the majority of individuals, particularly in the pediatric age range, are driven by dietary allergens. EGIDs have generally been thought to be rare; however, some studies have shown that their prevalence is comparable to other inflammatory GI diseases and appears to be on the rise.(Rothenberg, NEJM) Current diagnostic and treatment options are limited.
- Non-IgE mediated food allergy, such as food protein-induced enterocolitis and proctocolitis, may present as acute severe gastroenteritis or chronic enteropathy depending upon the frequency of exposure to the offending antigen. The immune mechanisms are poorly understood, and although most often a pediatric problem with favorable prognosis, some patients have more persistent disease and there is currently no testing available to predict offending antigens or prognosis.
- Celiac disease (CD), an immune disorder of the small intestine triggered by the response to a protein called gluten that is found in most grains, and present in common items such as pasta, cereal, and many processed foods. In the general population, 1 out of 133 people suffer from celiac disease, while the number rises to 1 in 22 in those with first degree relatives who have the disease. Undiagnosed and untreated, celiac disease can lead to malnutrition, the development of other autoimmune disorders, as well as osteoporosis, infertility and neurological conditions. To stay well and avoid damaging their small intestine, people with CD must be on a strict gluten-free diet for the rest of their lives.
The solutions to easing or eliminating the discomfort and anxiety caused by food-related diseases lie in the development of better diagnostic methods, treatments and means for prevention. Such solutions may be within reach sooner rather than later, and MGH is well-positioned to be a leading center of research in this area. As these answers are being sought, the MGH Food Allergy Center is providing state-of-the-art care for patients of all ages and a rich training ground for future specialists.
Features that Distinguish the MGH Food Allergy Center
Making an accurate diagnosis and prescribing proper treatment for patients suffering from any of the above disorders is a challenge for even the most experienced physicians. Therefore, MGH Food Allergy Center relies on a collaborative and collegial approach to care, engaging experts in pediatric and adult gastroenterology, pediatric pulmonary disease, allergy and immunology, dietitians, psychologists, clinical coordinators and social workers.
- Food allergies, atopic dermatitis, allergic rhinitis and asthma share a common genetic footprint and similar biological platform for setting immune mechanisms in motion. Therefore, the Food Allergy Center's integration of clinical specialists and investigators from related disciplines, e.g. gastroenterology and allergy, can spur innovative thinking and ultimately enrich the quality of care. This cross-over collaboration takes place in both the clinic and laboratory, providing the type of problem solving opportunities that cannot be generated when focusing on a single disease at a time.
- The Food Allergy Center's location within the MGH enables the center to leverage relevant studies that are part of the hospital's vast research enterprise, which is the largest hospital-based research effort in the U.S. For example, the Center will aggressively pursue translational collaborations with existing research entities such as the Center for Immunology and Inflammatory Disease and the Mucosal Immunology Laboratory.
- The Food Allergy Center's commitment to serve both children and adult patients provides advantages for patients, clinicians and researchers. For patients, the center offers continuity of care, a comforting and valuable consideration for adolescent patients and their families as they transition into young adulthood and beyond. Pediatricians and specialists in adult medicine can communicate their knowledge face-to-face and blend their skills, know-how and creativity in formal and informal circumstances to benefit patients of all ages. For researchers, the continuity of care of patients from childhood to adulthood provides a much-needed opportunity to better understand the natural history of some food allergic diseases, particularly allergic eosinophilic gastrointestinal disorders. Among all people affected by allergies who are seen at the MGH, approximately 60% are children and 40% are adults -- a fairly balanced mix of patients with a common spectrum of diseases whose treatment and study provide synergies that are not available in hospitals that specialize solely in pediatric or adult care.
- The center's team approach enhances patients' convenience and peace of mind. On a patient's initial visit the center's staff determine which combination of services is most appropriate given the patient's symptoms or diagnosis and then arranges appointments with each specialist, in a single day if possible. Thus, the MGH's ability to tailor expertise in multiple disciplines to the needs of each patient, regardless of age, distinguishes the Food Allergy Center's clinical programs and is a key factor in the delivery of first-rate care.
This singular clinical environment offers unique training opportunities for young physicians and investigators who represent the next generation of specialists in the study and treatment of food allergy and related conditions. The MGH has long been one of the world's premier "talent incubators" through its affiliation with Harvard Medical School, and the Food Allergy Center will help enrich the hospital's medical education offerings.
A Plan for Growth and Discovery
With a strong foundation of clinical services in place, the next steps in the Food Allergy Center's growth and development are to mount more aggressive and expansive efforts in basic research, clinical studies and translational initiatives that bridge the gap between the laboratory and the clinic.
Their dual mission will be to (1) deepen our understanding of the underlying molecular and biological factors contributing to food-related diseases and (2) convert lab findings into better diagnostic methods, more effective treatments, new means for disease prevention and ultimately cures. To aid investigators in achieving these goals the Food Allergy Center must build a research infrastructure that provides the necessary technical and administrative personnel, laboratory space and technology in both the center's clinical and research programs.
Examples of questions that the Food Allergy Center's research program could pursue include:
- What are the signaling pathways that lead a person to become sensitized to food? Are there ways to disrupt or block these pathways to prevent food allergy?
- What are the predictors of food allergy persistence and severity and how can we use them to prognosticate patients and develop new hypotheses about disease mechanisms that could lead to better interventions?
- What are the origins, triggers, symptoms and progression of the EGID family of diseases? Why is its incidence rising? What are the genetic contributions?
- Can a non-invasive test be developed to follow the course of eosinophilic esophagitis (EoE)? As of now the only way to monitor therapy is with multiple endoscopies, an invasive and uncomfortable procedure.
- Are there ways to block or eliminate the harmful effect of gluten on the small intestine?
Clinical Studies in Progress
Two clinical protocols have been developed with enrollment expected to begin by this summer pending IRB approval and funding:
- An interventional trial oral immunotherapy (OIT) for children with peanut allergy.
- An observational study on the efficacy of atopy patch testing for the prediction of food allergens in EoE.
In both of these studies, there will be a significant translational research component to evaluate mechanisms of immune modulation in OIT, focusing on basophils and B cells, and building a specimen bank and clinical database for EoE.
- Noel et al. Eosinophilic esophagitis. N Engl J Med (2004) vol. 351 (9) pp. 940-1
- CDC Study Finds 3 Million U.S. Children have Food or Digestive Allergies. CDC website. http://www.cdc.gov/media/pressrel/2008/r081022.htm. Updated October 22, 2008. Accessed March 17, 2010.