Review Article

The Diagnosis and Management of Food Allergy and Food Intolerances

J. L. Turnbull; H. N. Adams; D. A. Gorard


Aliment Pharmacol Ther. 2015;41(1):3-25. 

In This Article

Abstract and Introduction


Background Adverse reactions to food include immune mediated food allergies and non-immune mediated food intolerances. Food allergies and intolerances are often confused by health professionals, patients and the public.

Aim To critically review the data relating to diagnosis and management of food allergy and food intolerance in adults and children.

Methods MEDLINE, EMBASE and the Cochrane Database were searched up until May 2014, using search terms related to food allergy and intolerance.

Results An estimated one-fifth of the population believe that they have adverse reactions to food. Estimates of true IgE-mediated food allergy vary, but in some countries it may be as prevalent as 4–7% of preschool children. The most common food allergens are cow's milk, egg, peanut, tree nuts, soy, shellfish and finned fish. Reactions vary from urticaria to anaphylaxis and death. Tolerance for many foods including milk and egg develops with age, but is far less likely with peanut allergy. Estimates of IgE-mediated food allergy in adults are closer to 1–2%. Non-IgE-mediated food allergies such as Food Protein-Induced Enterocolitis Syndrome are rarer and predominantly recognised in childhood. Eosinophilic gastrointestinal disorders including eosinophilic oesophagitis are mixed IgE- and non-IgE-mediated food allergic conditions, and are improved by dietary exclusions. By contrast food intolerances are nonspecific, and the resultant symptoms resemble other common medically unexplained complaints, often overlapping with symptoms found in functional disorders such as irritable bowel syndrome. Improved dietary treatments for the irritable bowel syndrome have recently been described.

Conclusions Food allergies are more common in children, can be life-threatening and are distinct from food intolerances. Food intolerances may pose little risk but since functional disorders are so prevalent, greater efforts to understand adverse effects of foods in functional disorders are warranted.


Although food allergies are commonly encountered by paediatricians, and although the public and lay press demonstrate a marked interest in food allergies and intolerances, this diagnostic arena is little regarded by most gastroenterologists dealing with adult patients. Adverse reactions to foods vary in clinical presentation, severity and underlying aetiology. Patients, the public, doctors and other health professionals frequently confuse non-allergic food reactions with food allergy.

Adverse reactions to foods can be broadly divided in to those with an immune basis – food allergies and coeliac disease, or those without an immune basis – termed food intolerances (Figure 1). Although coeliac disease is a T-cell mediated (type 4 hypersensitivity) immune response to gluten, it is not usually classified as a food allergy and is not discussed further.

Figure 1.

Classification of adverse reactions to foods.

Acute toxic reactions to food contaminated by bacteria or by aflatoxins, or to food containing excess histamine such as spoilt fish (scombroid food poisoning), are not reviewed here. Furthermore, adverse reactions to foods arising from metabolic errors (usually autosomal-recessively inherited enzyme deficiencies) and culminating in serious disease such as phenylketonuria, tyrosinaemia, organic acidaemias, homocystinuria, Refsum's disease, galactossaemia are not discussed. Malabsorptive problems such as abetalipoproteinaemia and pancreatic insufficiency in which fats aggravate bowel symptoms are similarly not included. Although dietary intervention can influence Crohn's disease[1–3] and orofacial granulomatosis,[4] the role of food in these inflammatory illnesses is also beyond this article's scope.