Why is it necessary to eliminate milk in casein allergy?
Casein is the main thermostable allergen of milk and the most important allergen of cheese. It is an allergen with a high risk of causing an anaphylactic reaction. People with a casein allergy cannot tolerate milk in any form, as casein is resistant to digestive enzymes and the high temperatures used during thermal and technological processing.
Czy mając alergię na kazeinę można spożywać mleko kozie?
There is a belief among some in society that people who are allergic to cow’s milk can replace this product in their diet with goat’s milk. Casein allergy shatters this belief. The structure of cow’s milk casein shows a very high similarity with the structure of goat’s and sheep’s milk casein. The similarity is up to 90 per cent, so people who are allergic to this protein should not include milk from these mammals in their diet. Replacing cow casein with sheep and goat casein may put the patient at risk of an allergic reaction, including anaphylactic shock [1].
What do casein and soy have in common?
Casein is a protein that shows cross-reactivity with soy protein. People who are allergic to casein may develop an allergic reaction after consuming soy or soy-containing products, in the form of skin lesions, oral allergy syndrome, gastrointestinal disorders and anaphylactic shock [2].
The role of the dietitian in the care of patients with casein allergy
The basis of dietary management is the complete elimination of cow’s milk proteins from the diet and the introduction of substitutes. In the case of breastfed infants, the elimination diet is introduced by the mother. It should be emphasised that such a restrictive diet should be agreed with a dietician, as it is associated with the risk of nutritional deficiencies. Children up to the age of 3 are most at risk. This is a time of intensive development and the nutrient requirements of this group are higher than those of adults. The results of a study of 9,500 children under 2 years of age with food allergy showed that one in five children had symptoms of malnutrition and one in four children showed slowed growth [3].
Periodic dietary assessment in people eliminating cow’s milk protein is essential to determine daily intake:
– proteins
– calcium
– vitamin D
– vitamin A
– phosphorus
– riboflavin
– pantothenic acid
– vitamin B12 [4.5]
Nutrient requirements are determined for each individual, as they are influenced by a number of factors: age, gender, physiological status, co-morbidities and medication [6].
The role of adequate intake of calcium, phosphorus, and vitamin D in bone mineralization
Proper nutrition of the body is key to maintaining healthy bones. An adequate supply of calcium ions, phosphorus, vitamin D, magnesium and protein positively influences normal bone mineralization [6,7]. Calcium has a number of important functions in the body. It is involved in nerve transmission, muscle contractility and blood clotting processes [8]. An inadequate intake of calcium ions and vitamin D forces the body to obtain this element from its own internally stored tissue sources. Dissolution of the skeleton takes place and the necessary calcium ions are released into the bloodstream, which can result in a decrease in bone mass and lead to osteoporosis [7]. In children, rickets may occur. Calcium deficiency can also lead to neurological disorders and tetany [6]. Individuals eliminating dairy products completely from their diet, which are the main source of calcium in the diet, should include supplementation containing organic compounds of this element, i.e. gluconic or citric acid salts. Organic calcium compounds are also present in food, and the body shows a greater capacity to absorb and retain them [7]. Certain proteins, i.e. lysine and arginine, and prebiotics, i.e. fructooligosaccharides and inulin, further enhance calcium absorption [9].
Products rich in calcium, vitamin D and phosphorus
- kale
- parsley leaves
- dried figs
- dried apricots
- nuts
- almonds
- poppy seeds [10]
Another important element involved in bone mineralisation is phosphorus. It interacts with calcium, participates in the body’s energy metabolism and helps to maintain the acid-base balance [6]. It is quite widely available in food products, so practically no deficiencies of this element are observed today [9].
Phosphorus-rich products:
- wheat bran
- oat flakes
- rye flakes
- buckwheat groats [10]
At this point, attention should be paid to the excessive consumption of highly processed products, which are a source of phosphates. These compounds further increase the daily intake of phosphorus with the diet and contribute to excess phosphorus. As a result, the absorption of iron, zinc, copper, and magnesium is reduced, which can also lead to a decrease in bone mass.
Vitamin D is another important component for the body to utilise calcium correctly. The active forms of this vitamin increase calcium absorption in the small intestine and influence calcium deposition in bone tissue [9].
Products rich in vitamin D:
- salmon
- herring
- rainbow trout
- smoked eel [10].
If deficiencies are identified, vitamin D dosage should be individually determined by systematically monitoring its blood concentration. During supplementation, calcium and phosphate metabolism should also be monitored by blood tests [11]. Vitamin D belongs to the group of fat-soluble vitamins, so it is recommended to take its vegetable oil-soluble forms with meals [7].
Casein allergy, which milk substitutes to choose?
By eliminating milk completely from the diet, we aim to replace this ingredient with suitable substitutes.
- We replace milk with plant-based drinks: oat, rice, millet, almond, hazelnut or coconut. It is important that such a drink is enriched with calcium in an amount similar to that found in cow’s milk, i.e. 120 mg of calcium per 100 ml of drink. We can use these drinks to prepare oatmeal, puddings or vegan ice cream [12]. A complete exclusion is made for soya beverage because of the cross-reactivity between casein and soya proteins [2]. Care is taken to ensure that rice drink is not the main and only substitute for milk, as rice has a natural ability to accumulate arsenic, which can contribute to cancer [13].
- Replace traditional cream with plant-based cream based on oats, rice, coconut, spelt, and almonds.
- Replace butter for bread spreads with avocado paste or vegan mayonnaise.
- Vegetable oils can be used for baking, i.e. rapeseed oil, grape seed oil or coconut oil.
- Yeast flakes can be a substitute for yellow cheese and are ideal for topping pizzas, casseroles, pasta casseroles and thickening soups.
- White cheese can be replaced by a paste made from almonds or nuts [12].
With these substitutions, an allergic person can still enjoy traditional dishes without the risk of triggering an allergic reaction.
How long should an elimination diet last?
Casein allergy is assessed periodically. The concentration of E antibodies is tested for this purpose. When a decrease in their number is observed, this indicates a gradual increase in tolerance [1]. In order to determine whether it is possible to start including milk in the diet, an oral provocation test should be performed, which takes place in a hospital setting. If such a test does not induce allergic symptoms, expansion of the diet with dairy products can be started. However, if symptoms are still present, the elimination diet should be continued [14].
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translation: Julia Majsiak
