Medsarticles. Medical Weblog

I have attempted to explain the concepts of clinical ecology in terms of adaptation to environmental exposures—a framework borrowed from physiology. In biology, when an organism comes into contact with a new element in its environment, it often responds in three stages: first, there tends to be an immediate acute reaction; this may be followed by an adapted stage in which there is a suppression of reactive symptoms; and finally, the organism may become maladapted, and perhaps later, nonadapted to repeated exposures by again presenting immediate, acute symptom responses.

Since new patients usually first come to their physicians midway in this process, they tend to present quite a different clinical picture than observed in laboratory animals. Instead of the sequence noted above, patients are first seen by their physicians as their adaptation to that to which they are susceptible is petering out. To what and for how long they had been adapted to such a frequently repeated exposure, which had maintained a relatively stimulatory phase, remain unknowns. Indeed, such a substance often appears to agree with an adapting person very well. But sooner or later—largely depending on the degree of individual susceptibility—such a person slips into a withdrawal phase for longer and longer periods. In other words, he completes this transition (usually called the onset of the present illness) and is now maladapted (badly adapted).

Such a transition from an adapted and relatively symptom-free existence to chronic illness often involves many side trips, including various levels. The speed with which this transition takes place is also partially dependent on the patient’s awareness of his problem. If he remains totally unaware of the environmental cause(s) of his symptoms, the transition may take place fairly rapidly, If he is aware that eating in general, for instance, agrees with him, he may be able to slow the onset of maladaptation, although he may become progressively obese in the process. And finally, if the patient is aware of the particular food(s) related to his symptoms, he may be able to delay his ultimate downfall by a judicious intake of the particular culprit. Eventually, however, most patients lose their symptom-suppressed adaptation to such substances and wind up in a doctor’s waiting room. Unfortunately, there is another outcome which may occur at any stage of this adaptation process to food(s). Some patients, suspecting that all food and/or food additives and contaminants make them ill, simply stop eating. This may lead to a marked loss of weight and hazardous undernutrition.

For the reader interested in greater detail, adaptation is defined as the ability of an organism to be modified in its function by the impingement of its environment. In the specific and individualized sense employed here, adaptation is limited to observed clinical manifestations resulting from the impingement of given environmental exposures to which individuals are highly susceptible.2,3 Adolph also observed similar effects in animals.4

Environmental features contributing to specific adaptation are the following: a) Given exposures must be cumulative and preferably intermittent. Those substances, such as common foods, retained in the body temporarily are most effective in inducing and maintaining specific adaptation. b) Specific reexposures should be approximately the same size, and rate of absorption through a common portal of entry. c) Given environmental exposures may be harmless (foods) or alleged to be toxic in greater concentrations, although thought to be safe in the lesser amounts encountered (chemicals).

Bodily features contributing to specific adaptation include: ability of an individual to adapt; this probably depends on: a) inherited tendencies, b) adequacy of apparent physiologic mechanisms,5-8 and c) variations in the degree of specific susceptibility, inasmuch as a heightened susceptibility seems to enhance the impact of lesser dosage and accelerates the advancement of the adaptation process.

Because of these environmental and bodily (individual) variants, adaptation to given environmental exposures develops and advances more rapidly in some individuals than in others. For instance, one person may present only a few localized syndromes from only a few environmental exposures, whereas another person may manifest many apparently different physical and more advanced cerebral and behavioral syndromes from multiple exogenous exposures. More over, such lesser and advanced responses may alternate in a given person at different times.9 This alternation of what later were called allergies (rhinitis, asthma, eczema, and headache) with psychoses was apparently first pointed out in 1884 by George Savage, an English psychiatrist. In contrast to this highly individualized interpretation of adaptation to specific environmental exposures, traditionally physiological adaptation has been presented elsewhere in respect to its general features and common bodily mechanisms.5-7 Since a given individual is adapting not only to common foods and lesser chemical exposures, but also to many other environmental stimuli— such as infection, cold, heat, radiation, etc.—the ability to adapt or maladapt must also be considered in a broader context. For instance, it is known that virus infections frequently induce or precipitate maladapted allergic responses to other materials. The same relationship holds for systemic yeast infections,11 and sometimes other infectious processes. Adequate treatment of a concomitant infection in the management of allergies must always be considered. It is also well known that sudden exposure to cold in some persons may be generally deleterious. Although the relationship of these secondary factors in adaptation is important, a detailed discussion of them is beyond the scope of this popular presentation.

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These drugs have the effect of stabilizing mast cells so that they do not release histamine and other mediators. The main one used is sodium cromoglycate. It is only effective if it reaches the mast cell before the allergen. So it can be used to prevent the symptoms of allergy, as long as the patient remembers to take the drug when they are feeling well, before they encounter the allergen.

The drug is given in inhalers (Intal) as a preventive treatment for asthma. The time from when treatment starts to when the good effects become noticeable is variable – from a few days to several weeks. The drug must be taken continuously to be effective. In some people, it can cause irritation of the throat, coughing or, more rarely, an asthmatic attack. In rare cases there may be a true allergic reaction to the drug. In general, however, sodium cromoglycate is remarkably free of side-effects.

Although the main effect of sodium cromoglycate is to stabilize mast cells, it appears to make the bronchi less reactive in other ways as well. Thus it is used for exercise-induced asthma. Its long-term effect is to make the bronchi less sensitive, which is beneficial.

A related drug, nedocromil sodium (Tilade), is sometimes prescribed instead of sodium cromoglycate for asthma. It acts in much the same way but is a more powerful drug, and is not prescribed for children. Sometimes sodium cromoglycate is combined with other drugs, as in Intal Compound which contains isoprenaline.

In cases of food allergy, taking sodium cromoglycate by mouth (Nalcrom) can block the allergic reaction. But it is only used where the symptoms are not of the immediate-and-violent kind. Thus it might be prescribed for patients with food-induced symptoms such as diarrhoea, asthma, rhinitis, eczema or chronic urticaria, but not for those who suffer swelling of the mouth and tongue on eating a particular food. In such cases, the slight risk of the drug not working has to be considered, because of the serious consequences of such a failure.

Sodium cromoglycate appears to block mast cell degranulation in the gut wall, which prevents the gut wall becoming inflamed and thus makes it less permeable to food molecules.

To be effective, sodium cromoglycate (taken by mouth) must be taken 10 or 15 minutes before the food is eaten. The beneficial effects of the drug may not appear for several days. Occasionally, the drug may make the symptoms worse, for reasons that are not yet understood, and sometimes it has no effect, or only

partially controls the symptoms. Sometimes patients experience side-effects such as headaches, urticaria, diarrhoea or vomiting.

Because of doubts about its effectiveness if used long-term, simply taking sodium cromoglycate is not the best way to deal with food allergy. Its main use is in patients with reactions to a very wide range of foods, who find it difficult to avoid them all. Even though they are taking the drug, such patients must usually restrict their intake of the main offending foods as well. Babies who react to a wide range of foods on weaning have been helped by sodium cromoglycate.

This drug can also be useful in giving food-allergic people a ‘day off from their restricted diet. Children may be given it for Christmas or birthdays, to allow them to eat normally for a day. Sodium cromoglycate is also used in hay-fever and other forms of allergic rhinitis (Rynacrom) and in allergic conjunctivitis (Opticrom). It can cause stinging when applied but this wears off quickly and again there are no serious side-effects. The drug must be used regularly and consistently for the good effects to be maintained. In Rynacrom Compound, sodium cromoglycate is combined with xylometazoline, a sympathomimetic .

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Wait until you have been free of symptoms for two or three days, but don’t wait any longer than this. Begin by testing foods that are probably not the cause of any trouble – things you do not eat very often. Choose items that you like – if the foods pass the test, then you can incorporate them into your menus, which will allow you to eat less of the exclusion-phase foods. Throughout the reintroduction phase it is vital that you keep your diet varied and do not eat too much of any one food. In particular, do not eat any one food every day. Continue to record everything you eat, and your symptoms – if something goes wrong, this record will prove invaluable.

Only test one food at a time. Eat a normal-sized portion of the food in question, preferably with your evening meal. Notice any changes that occur at the time, or later in the evening, or the following day. During the first five weeks of testing, test each food for one day only. (Although eating the food for three days in succession is preferable, it takes so much time that you cannot test enough foods – there are far more to test than on Stage 2). If you think you may have reacted slightly, but are unsure, then test the same food again the next day.

After five weeks, your sensitivity may be declining, so you need to test each food more thoroughly, by eating it for three days in succession. If you get no reaction by the fourth day, then the food can be considered safe, but avoid it again for four days (to offset any possible effect of eating it for three days in succession) before beginning to eat it once more.

If you get a reaction to any food, stop eating it immediately. Allow the symptoms to subside before testing any more foods.

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Although all elimination diets work on the same principle, doctors differ considerably in the sorts of food they allow during the exclusion phase. The objective is to avoid all foods that are likely to cause problems. In essence, this means all foods that are eaten frequently because these are the most likely culprits. However, the ’safeness’ of foods is also taken into consideration – some foods seem less likely to cause problems than others. The question is – how far do you take this? Some patients will be sensitive to 20 or more foods – to get better, they need to avoid almost everything they normally eat. But these patients are a tiny minority. Most patients will be sensitive to between two and five foods. For them, a rigorous exclusion phase is not necessary – they simply need to avoid the most frequent offenders, such as wheat, milk, eggs, citrus fruits, yeast, chocolate and additives. On the whole, the latter group have a much easier task ahead of them in discovering which foods make them ill, so doctors tend to think more about the unfortunate patients with multiple sensitivities. With them in mind, they devise diets that will eliminate most commonly eaten foods, even if this means putting the patients with just a few sensitivities through an unnecessarily arduous regime. The approach to elimination diet that we recommend is a flexible three-stage procedure that provides the best possible diet for each type of patient.

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The first step for any parent is to decide whether their child’s behaviour really is abnormal. As Dr Philip Graham of the Institute of Child Health in London points out: ‘All normal children show some degree of aggressiveness, disobedience and antisocial behaviour: all at times show sadness, depression, anxiety and social withdrawal. All are at times unusually active and distractible. What makes a child a cause for concern is the severity and persistence of the problematic behaviour in question.’

Although a child like Matthew clearly shows abnormal behaviour, others with hyperkinetic syndrome may only be mildly affected. In such cases, it may be quite difficult to distinguish hyperkinetic syndrome from ‘normal’ behaviour – emotional upset and misconduct may be due to family tensions, lack of discipline, an unsettled home life, difficulties at school, or a great variety of other causes. It is very tempting for parents to attribute their child’s awful behaviour to some simple external cause when the real problem lies within the family. Conversely, some parents may find lively, childish behaviour disruptive and label it as ‘hyperactive’ when in fact it is perfectly normal. Parents may not always be the best judge of what is wrong with their child, and it is a good idea to discuss the problem with a sympathetic teacher, doctor or child psychiatrist, keeping an open mind about the possible causes of the problem.

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Antibodies are special molecules produced by the body to fight off infections. They bind firmly to the bacteria or virus that causes the infection and, with luck, this stops the infection in its tracks. Antibodies can block infection in a variety of ways. With viruses, they may be able to prevent them from invading the body’s cells simply by binding to them. With bacteria, however, antibodies alone are ineffectual. They need help to defeat the bacteria and their job is to act as signals to other cells and molecules in the body which have the power to kill. The antibodies form a coat on the surface of the bacterial cells and this stimulates the immune system’s ‘assassination teams’ to go into action against the bacteria.

Antibodies are protein molecules, as are many of the important, hardworking components of the body (see p23). Proteins are infinitely variable molecules and this is what makes them so useful. In the case of the antibodies, their versatility is employed in making molecules that bind specifically to a particular target molecule, or antigen, and to no other. The measles virus, for example, is bound by antibodies that specifically recognize proteins in the outer coat of the virus – these being the measles antigens. They do not normally bind to anything else, apart from the measles virus.

The body produces a vast range of different antibodies – millions of them so that if it has to combat a new bacteria or virus it is certain to find an antibody ‘in stock’ that is just right for it. The antibodies are produced by special factory cells called B cells, and each B cell produces its own particular form of antibody. When faced with an invading microbe, the body selects a B cell with the right antibody to match that microbe, stimulates the cell to divide, and then instructs all the cells that are descended from it to produce their much-needed antibody. This continues until there is enough of the correct antibody to defeat the infection.

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Stop using chemicals that you commonly use on yourself, or around the home. For best results, get a box or bag and go around your home, putting in it anything you find – such as toothpaste, soap, deodorant, shaving gels, the contents of your bathroom cupboard or shelves, talc, all perfumes and aftershaves, bubble baths, hair gels, sprays, mousses, cosmetics, baby wipes and lotions. Include all cleaning products -soap powder and liquid, fabric softeners, bleaches, disinfectants, toilet cleaner, bath cleaner, oven cleaner, washing-up liquid, polishes, shoe polish, everything. Remember to include air fresheners and toilet fresheners; remove any that are stuck to surfaces. Collect up any DIY products, gardening chemicals, and glues, sticky tapes, felt-pens or similar stationery products. Take anything you see. You will probably be amazed at how much there is.

Put the box or bag in a shed or outside the house where the fumes will not reach you. Open the windows and doors and air the place right through for a short while – a few hours or longer, if you can. Keep it well ventilated.

Use only basic personal hygiene and cleaning products as listed below for the length of the programme. Persuade people who live with you to use the same things if you possibly can, to reduce your exposure still further. The same things can also be used on babies and children.

• For tooth powder, use sodium bicarbonate or table salt

• For soap, use Simple Soap or Kay’s Vegetable Oil Soap

• For shampoo, use Simple Shampoo or Crimpers Shampoo

• For shaving gel, use Simple shaving gel or soap as above

For names of products that chemically sensitive people tolerate well for laundry, dish-washing, general cleaning and toilet cleaners. Use the products recommended there for the elimination period, or:

• For laundry, use Borax, or sodium bicarbonate or washing soda

• For dish-washing, use washing soda

• For general cleaning, use washing soda

• For toilets, use Borax

Only use drugs and medicines during the programme that you absolutely have to have. Consult a doctor about whether you can leave out or change any medication before starting the programme. If you use emollients or ointments for eczema or dermatitis, try to do without them completely during the test period – you may actually be sensitive to them. Do not use home medicines. If you cannot do without a painkiller, use Paracetamol rather than aspirin or other compounds.

Avoid doing tasks that use strong chemicals if you can, such as DIY, car maintenance, or using glues and solvent-based writing materials. Do not use garden sprays or chemicals. Avoid solvent-based felt-tip pens and white correction fluid.

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Paint strippers are of two basic kinds – organic solvent-based ones which dissolve paint, and caustic strippers which are applied as a paste, allowing the paint then to be peeled away. Avoid using solvent-based strippers as significant fumes are given off on use. Using caustic strippers is probably preferable to using a blowtorch, where you will have to deal with the fumes of the blowtorch and of the paint or varnish being burnt.

Caustic strippers are based on caustic alkalis, and can burn the skin on contact, but do not cause sensitivity. Take all usual precautions with face, hands and body when using irritant materials and handle all waste carefully.

Langlow make Safer Paint and Varnish Stripper which is water-soluble, and does not contain caustic soda, or methylene chloride. It is less irritant than other caustic strippers, but still requires careful handling. It is available from DIY shops, and Do It All.

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No independent test reports have been done for air filters and cleaners. The following assessment is based on the judgement of doctors and nurses, and the experience of a range of users with allergies and sensitivity.

If you are exceptionally sensitive to particles, such as dusts, moulds and pollens, or if you are very sensitive to chemicals, you should only consider higher efficiency machines.

Smaller filters

If you are not sensitive to chemicals, nor very highly allergic, most of the smaller filters will be sufficient to take out a high level of particle allergens and will be fine for most people’s needs. Some of the best small filters include the Trion Electrion, the NSA 1200A, the Medivac F400 and the Mountain Breeze F400. These all have a thin layer of activated carbon filter which takes out some chemical vapours, but they are not highly effective against chemicals. For filters which are, see below.

The Trion Electrion has an electrostatic filter, a thin carbon filter and a permanent ioniser (see above). It is small, unobtrusive and very portable. It is very quiet to run and has three speeds of operation. It has a marked effect on particles and dusts, according to people who have used it. Its price (at 1992) is quoted between £80 and £100. Its electrostatic filter can be washed; its carbon filters need replacing every six months, costing £7 each. It is available from Air Improvement Centre, Beta-Plus or direct from Trion (addresses below).

The NSA 1200A is larger than the Trion Electrion but still light, unobtrusive and portable. It has an electrostatic filter, a fabric filter and a thin layer of activated carbon. It has an optional fragrancer which you should not use if you are chemically sensitive. It makes as much noise as a quiet fan heater. You can buy a carrying bag for it which is useful if you wish to carry it around with you. It has good reports from users and samplers, but it is more expensive – about £150 at 1992 prices. (At this price, a more effective, but less portable, medium-size filter [see below] would be a better buy.) Filters (£20 each) need replacing every six months. The NSA is available from Beta-Plus or NSA distributors (addresses on pages 241-2).

The Mountain Breeze F400 and the Medivac F400 also receive good reports from those who use them. (These two are virtually identical machines.) They are generally viewed to be less effective than either the Trion or the NSA devices, but nonetheless make a difference to air quality and are worth considering. They are cheaper in price (about £70), with replacement filters (£6) renewable every six months. These devices have an ioniser built-in, an electrostatic filter, and a thin activated carbon filter. They have an optional fragrancer, and three speeds of operation. They are as small and unobtrusive as the Trion, but noisier in operation. They have a stronger smell of plastic when new, but this does wear off. These are available from Air Improvement Centre, Beta-Plus, Medivac or Mountain Breeze.

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If you are extremely sensitive to a food or foods, you may react even to the smell or vapours of the foods, or to handling them. You may also be affected by other people eating them in your presence, or if you go into canteens, cafes or restaurants.

To protect your hands when preparing foods, wear gloves. Use cooking methods that minimise cooking times and fumes. Ventilate well. Keep chopping boards separate if necessary to keep juices off your own food.

You may have to avoid public places where food fumes are found if you are badly affected. Members of your family or household may have to modify their diet and leave out things that upset you. Avoid situations that you know upset you.

Tiny traces of moulds adhere to cut or just prepared food, vegetables and fruit, and in refrigerators and freezers. These may upset you if you are highly sensitive to moulds.

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