Environmental Medicine in Clinical Practice [Paperback]

Since the late 1970s British and American allergists have been divided into two warring camps, each ascribing to the other stupidity, cupidity, or worse. Prof John Soothill once described the battle as "the blimps versus the nuts". Each group is represented in the UK by a learned society and a peer-reviewed journal, and each would like you to think that it represents the true voice of authentic "scientific" allergology.

In the blue corner, representing the "blimps", and supported by a veritable bombast of professors and Royal Colleges, we find the British Society for Allergy and Clinical Immunology (BSACI). In the pink corner, appearing for the "nuts", with fewer professors but fairly pawing the ground in eagerness, appears the British Society for Allergy, Environmental and Nutritional Medicine (BSAENM). The second group used to describe themselves as "clinical ecologists", which I think was a better description since it clarified their brief; they are as much concerned with toxicity as with immunology. Environmental Medicine in Clinical Practice is the acceptable face of clinical ecology, and contains a lot more hard science than you might expect.

As a career immunologist/allergist, I had watched bemused as the first clinical ecologists, led in the UK by Richard Mackarness, started to catch the media limelight with their tales of miracle cures in migraine and depression after simple dietary eliminations. Food intolerance is nothing new, and apart from the range o f conditions being treated, I wondered what was so newsworthy and why these upstarts were stealing our thunder. Clinical ecologists, as far as I could see, knew nothing about immunology, had never heard of us, and seemed to think that they had discovered allergy for themselves. And what about desensitisation?

We knew about injection therapy for pollen allergy, and we knew that skin-testing with protein allergens can sometimes provoke systemic symptoms. But the clinical ecologists were trying to tell us that if you injected exactly the right dose of allergen, you could also switch symptoms off! Sometimes within minutes! They called it "neutralisation". Obvious poppycock; these people were clearly mad.

I had to start changing my tune when in 1978 The Lancet published the first report, by Finn and Cohen, of double-blind food-challenge studies. These and subsequent reports proved beyond doubt that specific food intolerance can indeed cause quite unexpected symptoms. But "neutralisation" was something else, and I remained an implacable sceptic until I read W J Rea's paper (Arch Otolaryngol 1984; 110: 248-52) reporting a double-blind trial of this treatment. I had met Rea and respected him, and the study he reported was watertight. This paper, I thought, could mean only two possible things. Either Rea is lying, or neutralisation works. Soon other double-blind trials were published and I started trying the new, incredible method. For diagnosing allergies it was pretty useless, but used as a treatment method it doubled my ability to change ill people into well people. But few others joined me in crossing the floor. Conventional allergists, by and large, drew up in battle formation to discredit us, and were joined by one or two psychiatrists.

Why psychiatrists? Because we clinical ecologists invade their territory. Not that we aspire to take over the major psychoses, but we do have observations about the many medically unexplained symptoms that tend to be labelled as somatisation or hypochondria. Environmental Medicine in Clinical Practice gives a list of symptoms and syndromes that have been reliably provoked by double-blind challenge with specific foods. It includes nausea, lethargy, irritability, headaches, enuresis, and numerous other "medically unexplained" conditions. Less compellingly, but still strikingly, chapter 16 lists symptoms that frequently resolve as soon as nutrition is optimised and intolerances and allergies controlled; it includes aggressive and unreasonable behaviours, bulimia, anorexia, irritability, and mood swings. I describe these as less compelling because the challenges reported were not double-blind, but the parents, teachers, and in some cases police officers involved in caring for these patients have no doubts.

What else do the two camps disagree about? Food addiction, gut dysbiosis (the "candida hypothesis"), novel methods of desensitisation, the dangers of ambient chemical pollutants and of pharmacotherapy, the importance of micronutrients, and the causes of hyperactivity. This book adduces evidence for all it's views, much of it unashamedly based on the oldest clinical science of all, watching patients. The balance of the book is uncontroversial; allergists of either denomination could have written the chapters on aeroallergens, mechanisms, pollution, and economic aspects, showing that despite the differences, there is also much agreement between the two camps.

Any niggles about the book? Well, I don't like the terms "masked allergy" and "Type B Allergy". The first is used to describe the addiction-like state in which the damaging substance makes the sufferer feel better for a while, and the second for intolerance states mediated by unknown pathways. Both conditions exist, often together, but these names generate more heat than light.

That said, the book is timely, well written, well argued, well referenced, attractive, and cheap. The official line put out by traditionalists that "there is no evidence" for clinical ecology will not do; there is evidence, and these authors have presented it.(Extracted from ,THE LANCET l Vol 351, January 17, 1998 - reprinted with permission)

This is an important book. It is published by the British Society for Allergy Environmental and Nutritional Medicine, a society of doctors who concentrate on looking for the causes of symptoms, so that patients can take precautions and keep more or less symptom-free with little or no medication. This approach is increasingly being sought by patients. The book describes constructive ways of managing allergy. Allergy contributes, not only to asthma, eczema, and rhinitis, but also to migraine, irritable bowel syndrome, hyperactivity, arthritis and other conditions, as well as symptoms such as insomnia, restless legs and fatigue. The methods are particularly useful for patients with several allergies and for 'thick notes' cases with a number of different chronic or recurrent illnesses. Medical students and trainee doctors are taught to control these symptoms with drugs. However, many of them can be prevented by finding the cause, usually an environmental exposure, a food, or deficiency of a nutrient. In many cases, discovering the cause not only eliminates the symptoms but also results in positive well-being. Written by four doctors with long experience in the field, this is the first text to survey the evidence, quote the references, discuss the mechanisms, give information about how to guide patients to find out what is provoking their ill-health, and provide extensive instruction sheets which can be handed out to patients. Although written for doctors, other healthworkers also use it; some patients find it helpful and unexpectedly accessible.

This book can help you to keep your patients well.
Our aim, in writing this book, has been to make it easy for doctors to identify the triggers provoking many common illnesses. If this is done, patients can control their symptoms and need fewer prescriptions or consultations. A surprising amount of chronic and recurrent illness is due to environmental factors or foods: most appears to be allergic in nature although deficiencies of some essential vitamins and minerals also contribute.

Much of the allergy evidence comes from studies using double-blind challenges, mostly published in prestigious peer-reviewed journals but inexplicably ignored. For example, there are three studies in hyperactive children employing strict criteria and assessments. Each of the studies found that over 70% of the children improved markedly on an elimination diet, deteriorating with some open challenges but not others, confirmed subsequently by challenging double blind, yet these diets are little used.

This is a clinical book. We had no intention of competing with standard texts on environmental medicine but concentrated on ill-health that is not widely recognised as environmental, and on its management. Sadly, this is not yet taught in our medical schools. In the book we deal separately with each group of environmental factors, with each of the syndromes and symptoms which respond, and with the management of different age groups. In the appendix, we have included a range of instruction sheets and charts which can be copied for patients to make it easier.

A lot of common conditions do well with this approach including migraine, IBS, asthma, eczema, rhinitis, arthritis, back pain, mood changes, irritable bladders etc. Afterwards, patients usually need little or no medication. The patients do much of the work themselves; most co-operate well and are delighted to feel better and gain a measure of control. The approach is particularly appropriate for patients with ‘medically unexplained’ symptoms or suffering from many different conditions (thick notes cases); the degree of improvement in many of these cases disposes of the ‘psychological’ label.

All four of the authors trained in orthodox medicine, and still practise it when appropriate. Between us, we have experience in general practice, allergy, chest medicine and immunological and epidemiological research. We have all used the methods described in the book for many years, because we find them effective and satisfying.

The approach is not new, going back at least to Hippocrates, and the range of conditions which respond was first described in a treatise published in 1905. It has recently been suggested that the loss of tolerance causing these sensitivities represents an additional disease mechanism, as important now as the germ theory was when it was first mooted. Recognition of the nature of these conditions is becoming more urgent because of the continuing increase in their prevalence, imposing an increasing burden on general practice and hospitals. Some of the social implications are considered in the last section of the book, including those related to fertility and pregnancy outcome.

Doctors who try these methods for themselves are most unlikely to go back to relying on medication alone for these conditions. Those wishing to meet doctors who use these methods might consider joining the British Society for Allergy, Environmental and Nutritional Medicine. A list of doctors accepting referrals can also be obtained from the Society.

From the PREFACE This book is about an approach to chronic and recurrent illness which leads not only to improved well-being but also to a significant reduction in the use of drugs. It involves the search for the causes of symptoms ( particularly the exposures or foods that provoke them and the minor nutrient deficiencies which contribute. It is a taxing, but interesting and generally very rewarding way to practise. Most patients find it taxing, interesting and rewarding too: some of them have suspected that there must be provoking factors and are delighted to be helped to identify them. Others have no idea that this could be so: some of these are profoundly sceptical. Recently a woman with a 20 year history of increasing myalgia came back saying 'After my first appointment I was certain you were wrong and I determined not to try what you suggested. But my symptoms were bad and what you had said kept niggling in my mind, and eventually I decided that I must prove that you were wrong. So I followed your directions carefully to make it a fair test, and to my astonishment I'm much better. I used to have to stop five times on the stairs but now I can go straight up, except after I had tested x and y when I could not go up them at all.' Many doctors will be equally sceptical. All we would ask is that before you dismiss it you, too, give it a try.