Dr G Borok
B S c ( N r o d c s ) M B C h B ( R a n d ) 102 B;rrcllv Square
Cellicrs Street Sunnvsicle Pretoria
0002
Curriculum vitae
Dr Borok hls bcen ir.r both nrral and urban fian.rilv pr;rctice fbr 35 r,ears. In 1983, afier reading I)r M Mandell's booli "5 l)ir1'alleruv relief s1r513111", hc q.cnt tg Ame rica to learn thc techniqucs usecl bv Mar-rdell in his clinic in Nonyalk Conneticutt. For tlrc last 5 t,ears he has usetl an climination programtrte to rcsearch the relief of irritable boncl svnclrome and lll chronic svrrptorns of all st'stems of the boclr', associate d l ith the removal of fbods frorr patients. Hc had read p;rpcrs rlncl presented posters ou fbods in relation to rloods, astirnrl, migrair.re. IBS, hvpcrtension ancl behaliour rt r a r i o t r s e o n q r c s s c s . H c h c l t l J [urt tinlc ilppointme nt ;rt thc post coronrn' rehabilit.rtion programnle it the Sports Rescarclr Centre, University of Pretoria fbr l2 r.ears. He has 5 publicatior.rs to his namc.
Dr G Borok
Swwr.ruonty
Ten patients with exet cise-ind.wced.
&sthru& were pla.ced. 0n &n lliruina,tiltx prlgra.ru oJ' in h alants, shin app lications and. foods to ident'iJj, an)t ttiryJers which wet e associnted with bronchospasrn. AJier l/clnlying these trigqers the patients showerl. a signiJicnnt inct ense of lung function withoat lnnncbospastn on
exercise. Tbe outcorue of those patients wbo cowld. be traced. 1-2 years later, 'k giten, nr,td their treatwent, npecially
their dietary a.nd. eNercise tats, explained..
These f,.tcd.ings are cowpat"ed with filcd.ings of other yesearcbel,s rporld.-wide .
S Afr Fatn Pt"act 1990; lI: 355-62
I(EYWORDS:
Asthma; Diet; Hypersensitivity.
Introduction
10 patients u'ith excrcise induced astlima wcrc placed on an eliminatior-r progran-Ime of inhalants, skin
applications and fbods to iclentif,v anv triggers tltat u.ere associatcd \,r'ith bronchospasm. After rcmoval of thc triggers iclentified by thc programme, the ten patients showccl a significant increase of luns function u,ithout broncirospasmin exercise. On exposurc to triggers in the
laboratory, significant bronchospasn.r r,vas provoked, Six platicnts who werc tracecl I-2 r'ears later hircl significant increasc in lung functiorl. Fir,e n.ho ar.oidcd triggers had no significant exercise induced asthma. On cxposurc t() triggcrs at tl'ris stage lto significant bronchosplr,rst-u was prooucco.
Methodology
Ten paticnts with chronic asthma
crc pllt onto an elimination prograrxmc (EP) to identify
substanccs inhaled, absorbcd via the skin or eaten that u'ere associated u'ith pror,'ocation of bronchospasm.
The EP consisted of eliminating environntcntal fhctors sllch as all perfumcs, spravs, pets ancl house dust. Thc subjects could use onl-v non scentcd toilctrics and cosmctics.
Boilcd, soda or mineral \vater \\as the only fluicl allor,ved. Only one qpe of grain. fruit. vcgetable or prorein was caten Dcr dav. One or t\,vo items of fbod ir.crc ailowed per meal but could not be rcpeated in the same rveek.
Salt w.as thc only condiment ailou'ed.
At thc outsct lung furrcrion rvas rccordcd on a cavetron before and aftcr excrcise at the Sports Research Institute laboratorv, Univcrsity of Pretoria. A 15 20o/o reduction of fbrced expiraton'volumc in I second (FEV l) aftcr a ll-orldoaciat B5%
maximum u,ork capaciry indicated exercisc induced asthma (EIA) according to Jones.r
Lung function lr.as recordccl again, before and after exercise, one or t\\.o months latcr on the EP to
dcmonstratc any relief of EIA.
Patients were then re-exposcd to oflending inhalants or foods
identifred b-v thc EP, to conf-rrm their association u'ith bronch<>spasm in thc laboratonir.
Follow up three to t\,venf,v six months later: six Daticnts u'erc traced and Iung funition lr.as testcd on a plethysmograph at thc lung fhnction unit of the HF Verwoercl Hosoital.
Tlrc six t)ttieuts undcrwcrrt tlre' samc routine, showing in-rprovcment of lung function befbre ancl after exercise associated r,r'ith the remor,'al of triggers in foods and inhalants over the t\,vo years and thc r,vorsening
3 5 5 S A F a n r i l i ' P r a c t i c e I u l v 1 9 9 0 SA Huisartsprektvk lulie 1990
of lung function on exposure to triggers are reported.
Patient I
A 37 year old female patient suffered from recurrent colds, post nasal drip, sinusitis and headaches all her life.
Distension, colic and flatulence were ever present. Asthma bothered her for l6 1'ears, necessitatirrg hospitalisation on numerous occasions. Therapy ov€r the past I0 years comprised:
a) meticorten mg 5 B D continuously.
b) aminophylline suppositories B D.
c) salbutamol spray inhalation B-12 times a day prior to trial.
Favourite food or inhalants are often the culprits !
Her IgE level was 44IU.
Skin scratch tests:
Dog dander - ve Maize extract + Bermuda grass ***.
Exercise Induced Asthma
At start oftrial her FEV I decreased by 34o/o afte r rwo minutes exercise at 135 W, diagnostic of EIA as seen in Fig I.
Avoiding two inhalants: "Spray'n cook" and dog dander; and four foods: apples, white bread, artificial orange and granadilla cold drinks (identified by the EP) her lung function improved. After only eight weeks on the EP her FEV I increased
... Asthma and Foods
by B7o beforc exercise and decreased by only 9o/o after exercise of 135W, indicating no EIA.
After eating 3 bread rolls in the Iaboratory, bronchospasm was noted by a I3%o reduction of FEV I without exerclse.
The bronchospasm was relieved by inhaling salbutamol.
Though maize showed * positive on skin scratch testing, mcalies or mcalie meal did not affect her.
Twenty five months later her FEV I increased try |4o/o before exercise and
l3o/o after exe rcise . On re-exDosLrre to brcad and oransc drink her FEV I had improve d6:y l4o/o compared to two years prenously.
This oatient is addicted to wheat and eats 6read knowing the salbutamol
will help her. She nearly lost her life at a party when she had sandwiches, her favourite chocolate cake and an artificial granadilla drink. All three together provoking an extreme bronchospasm, the salbutamol inhalation not l-relping.
Except for this cpisode, necessirating admission, she has been off all
therapy for the past three years.
Occasionally salbutamol is used when she eats bread.
Patient 2
A27 year old female who suffered from urticaria and hayfever most her lifc and asthma for ten years, espccially at horse shows which she loved. She had a positivc IgE to horse hair. Stroking of horses outside the laboratory brought on an acute attack of urticaria but no asthma. She was a hear,y smoker,25 cigarettes a day.
3 WEEKS BREAD LATER EXPO$URE
25 MONTHS BREAD
LATER EXPOSURE
.l
2 . O
1 , 5
,]
U , D
0
I zo uor.rtHs LATEF F;?
M R 8 . A . M
POST tiIET i-I BFEAD EEFO,SUFE
B F E A D E : { P O S U R E
PRE-E. . PCST_E' PFE-E.H. POST-E EY.POSIJREPRE-E./, POST-E..hEXPOEURE
Fig ). Sbowing lwng function, FEV I in litres before (pre X) nnd. nfter exercise (post X); a) initially, blanh colwm.ns b) after 3 weelu d.iet, blnch colwnns. c) exposwre to brend' light d.oned. pottern. d) 25 wr.onths lnter" hatched. pa.tte?,n. e) nfter gxplsute t0 bread. again, henvy d.oned. pa.ttel4a.
356 SA Family Practice July 1990 S A H u i s a r - t s p r a k q k f u l i e 1 9 9 0
i--r
a
1
0
t , 1 R E . . t . L .
n pFE,DIET i:Tl po*l rttrr l.-.-l ctslRrttr / EFAtitiy I :ar t";oHfHE rgrrR i;;l ctGARETTE ,i gRAtJti
P F E - E tl P O S T - I I P B E - E r . . P O S I E f E ' P O 8 ! E E F E F ' E X P O . 5 T _ E ] / E i P O S L ] F E
Fig 2. The sarne as Fig 1 except the eNplsure i.s k and.y balk and cigat"ettes. Though IgE positive to hot"se huir, exposwr"e lead. to seyer"e ut ticat io ond not asthnco.
aminophylline and salbutamol inhalations continually for threc vears.
Iwestigotions I g E 2 3 5 I U .
Skin scratch tests: mites +++, grass ****.
FIer favourite fbods, Worcestershire Sauce (r.vhich she poured over most of her foods) and fruit salad yoghurt (no other flavours ofyoghurt affected her) were found to be the triggers of lrer asthma causing a 20o/o reduction of FEV 1. Removal of house dust mite relieved her of earl1, morning wheezing.
Two years later on re-exposure to Worcestershire Sauce and fiuit salad yoghurt her FEV I showed no dccrease but actually incrcased by 25%. She remained symptom free without any treatment as she totalll, avoided the triggers. Thc housc dust mites being starved by spraying hcr bedroom contents with a commercial b a r r i e r s p r a 1 . S e e F i g 3 .
She used salbutamol inhalations, average 5-6 times a day. The EP revealed the trigger of her asthma was passive cigarette inhalation.
Removal of this factor led to relief of EIA and a 20% reduction ofFEV I on exposure to cigarette smoke in the laboratory. She smoked intermittently but had stopped for 3 months prior t o l e s t i n g 2 v e a r s l a t e r a t t h e l u n g function unit. In the interim she found out she reacted to brandy balls.
O n e x p o s u r c r o h o t h b r a n d y b a l l s and passive cigarette smoke, though she produced a 33olo rcduction of F E V 1 . t h e F E V I w a s h i g l r e r t h a n exposure alone to cigarette smoke, 2 1'ears previously. See Fig 2.
Patient 3
A 26 year old female suff'ered all her life from nasal svmptoms and asthma, especially carly morning, the so-called early morning dipping. She r'vas on Cortisone inhalations, long acting
Fig 3. The sntue as Fig I except the exposwre is Wot cestershire sauce awd. fi'wit salod yoghutt.
STAFT F E V l ( L J
3 WEEKS LTTER
w/sAUcE 24 MONTHS W/$AUCE YoGHURT LATER YOGHURT
f-l prr-arr =
I z+ vct'fiHg LATEE ll:-]
h l F . g . J , G ,
trosr D]ET F.l 1'r,,,,9;1tgq + '',ocHtBT
\fuIEAU.T + ./OGHLJRT
FFE EX FCST EX. FFE EiI FOGT E.".F:/.PO5'JBE PEE_EJ( POfiI-E:hE}(PO3I.,IFE
357 SA Family Practice Julr. 1990 S A H u i s r f l \ I r r . r l < t y l t l r r l i c I 9 9 Q
S WEEKS GRASS LATER /TOMATO
2I MONTHS GRAS$
LATER /toMAto
A
1
o
f -] pRr-otEt I zr tlot'ttHs LntER
M F , H , v , Z ,
El post-otrt l-]-] egnss / ToMATo
1..-l GRAss / TorilATo P R E E X P O S T _ E X P R E - E X P O S T _ E X E X P O S U R E P F E E X P O S T - E } E X P O S U R E
... Asthma and Foods
Fig 4. Tbe sarne as Fig l except explsat/e isfr.eshly cutgra.ss, rnusltyoorn sa.ucq tlyna,to and, cold. d.rink.
Reduction of FEV I after only 3 weeks on the EP on re-exposure was 38%. See Fie 4.
Patient 5
A 19 year old male had suffered from asthma since an infant. He had been admitted to hosoital on numerous occasions and received cortisone, long acting aminophylline and salbutamol inhalations as therapy.
Able to function with 4 5 salbutamol inhalations daily he jogged to keep fit, needing 1-2 inhalations before and during mnning. His skin reaction to mites was *** oositive.
Foods are common triggers
On exercise his FEV I dropped by 23o/o. After avoidance of bread and yoghurt his FEV I only dropped by 7o/o after four weeks. On re-exposure to yoghurt and bread three months later FEV I improvement was 317o without salbutimol. Early morning wheezing disappeared after spraying his bedroom with a barricr sprav. See Fig 5.
Skin scratch or IgE was helpful but could be misleading
Patient 4
A 35 year old male was using 9-10 salbutamol inhalations daily. The EP revealed he reacted to mushroom sauce, tomatoes, cordials, ice cream and fresh grass cutting. On exposure to grass cuttings exercise produced a 3870 reduction ofFEV l.
IgE low.
Skin scratch oositive to mite which caused rhinitis.
Avoidance of these factors for two years, on exposure to grass cuttings, exercise now onlv produced a20o/o
. - - . ; i * ,
reductron ot.b.bV l.'Ihe FEV I now being 1,38 litres higher.
3 WEEKS YOGHURT 3 MONTHS YOGHURT
LATER /BREAD LITER /BREAD
'+
3 7
1
o
fl pRr-orrr E I e uonrHs rrrrn tII
M F , G , E , P O S T - D I E T F O O D E X P O S U F E
l.--l roon E.{posuFE P R E - E X P O S T - E . I P H E _ E X P G S T _ E X E X P O S U R E P R E E { P O S T _ E } E X P O S U B E
Ftg 5. Tbe sowae as F'ig 1 except explsuye as brend, nnd, yoghurt.
358 SA Family Practicc July 1990 SA Huisartspraktyk fulie 1990
Patient 6
A 38 year old female, a non smoker, had sinusitis and asthma for twenty years. At the start of the trial she was on:
a) Cortisone: i) orally alternate days ii) inhaled, 3 times daily.
U) !q:g acting aminophylline, twice oa[v.
c) 4-5 salbutamol inhalations a dal'.
After the EP her initial FEV I (drop of 34o/o on exercise) improvcd by 460/o after exercise.
On exposure to wine the FEV 1 dropped by 4|o/o. Two years later her FEV I before exercise, though 160lo better, still showed the same 37olo reduction on exDosure to wine despite having had sodium cromoglycolate. long acting aminoohvlline and salbutamol inhalatlion, which she usually took, halfan hour before the test. She
would not forgo her wine at night and opted for therapy. See Fig 6.
Results
At the start of the trial the six patients showed a significant reduction of FEV I (9570 lower confidence limit) of 0,4I litrcs (L) after exercise at B5o/o of maximum work capacity, indicating EIA. After tirree to ten weeks on the EP thcre was a significant improvment of FEV I of0,19 L bcfore exercise and of 0,3I L after exercise, indicating no EIA.
Directly after this exercise on
exposure to offending triggers the six patients showed a significant
reduction of FEV I of 0,56 L indicating asthma.
Three to twenty five months later the five patients who avoided offending inhalants and foods l-rad a higher FEV I after exposure to offending
triggers, except one, who still drank wine. After exercise alone, no significant reduction of FEV I was observed.
Discussion
The relief of the asthma in the six Datients was associated with the iemoval of certain inhalants and foods, which confirms the work of I(aplan,2 LessoF and Wilsona. The inhalants the patients were exposed to in the laboratory were passive cigarette smoke and freshly cut grass.
Removal of house dust mites, though not shown in laboratory played a clinical role. The six foods associated with FEV I reduction in the
laboratory (bread, brandy, yoghun, wine, Worcestershire Sauce and rnushroom sauce). have a
fermentation process involved in thcir manluacture.
Other foods such as apple, ice cream, tomatoes and cold drinks were involved. In total I3 different foods and 7 inhalants were involved, a ratio of two fbods to one inhalant. This is the same as the author's exoerience in 50 asthmatic cascs, where iy-pto-t imoroved in nine cases and were relicved in 37 cases. Asthma was provoked in 620/o of cases by foods, 32o/o by a combination of foods and inhalants and only 60lo due to inhalants alone.s
In five out of six cases the asthma was provoked by the patient's favourite foods or inhalant in addition to envi ronmental factors. The favourite foods are most often eaten,
aggravating the situation, but even worse, sonrc are addicted to these foods and cannot let them so6 as occurred in two patients.
Two vears later three Datients who had abstaincd from .*poro.. to
START F E l i l { L )
9 WEEKS WIHE
LATER EXFOSURE
2 O M O N T H S W I N E
LATER EXFOSURE
?
1
0 . 6
0
f-l psr-orrr W I ze Mcl.trHs rnrrn F;l
M F S , A . d J , P O S T - D I E T W I N E E X P O S L J F E
l-::l wHr ExposuRE P F E _ E X P O S T _ E ' 4 . . P B E - E X P O S T - E € Y P O S U B E P B E - E X P O S T - E } E X P O S U B E
Fag 6. The sa,?ne a,s Fag I except tbe exposwre is wine.
359 SA Family Practicc July 1990 S A H u i s a r t s p r i r k t v k J u l i e 1 9 9 0
triggers had signifi cant improvement ofFEV I after exercise and exoosure to offending foods, and had no EIA.
The two patients who partially abstained from exposure to offending foods had insignificant EIA and a smaller decrease of FEV I on exposure to offending foods without therapy, except when they
transgressed. After two years the one patient who preferred treatment rather than give up her wine still had EIA and bronchospasm on exposure despite full treatment of
cromoglycolate, aminophylline and salbutamol inhalation half an hour before the test as part ofher regular daily dosage. All four patients who were on cortisone before the EP did not need it afterwards. The longer the patients avoided the offending foods, the less the bronchospasm induced by exercise, inhalant or food. It is suggested that this may be due to the inflammatory reaction having subsided after removal of the irritating chemicals in triggers.
Skin scratch or IgE testing was helpful but could be misleading. Two patients with early morning wheezing had *** positive skin scratch test to house dust mite. The earlv mornins
... and she remained symptom free without any treatment as she totally avoided the triggers
wheezing was relieved by spraying the bedroom contents with Bayer's anti- mite spray. It is suggested that bed room contents and vaoours such as plants, pillows, perfumes and mites are responsible for early morning dip- ping and not necessarily low dose of therapy at thar time when exposure is at its height.
... Asthma and Foods
In this trial one patient who had raised positive skin scratch test to maize did not react to mealies. Shc developed asthma on exposure to her dog but the skin scratch test to dog hair was negative. The *** positive skin scratch test to horses was the cause of urticaria and not asthma in a second patient. Lessofet al found that five oatients.with milk
All six patients showed signifi cant improvement after 3-10 weeks on the elimination programme
intolerance with asthmatic episodes had IgE values less than 40u,/ml to milk.3
Various reports by Mandell,6 British Nutrition Foundation,' Lessof et al,3 and Allen et al,* have shown relief of asthma by removing foods from the diet.
Though some patients have a raised IgE to dogs, mites and feathers, these may cause eczema or rhtrutls
commonly associated with asthma but not the asthma. The asthma in these cases may be caused by the salicylates (tea, oranges, honey), benzoates (fruit juices) or sulphites (sausages, eggs, sugar).8
Bronchial hyperresponsiveness is described today as being more due to inflammatory cell infiltration with thickening of basement membranes and muscles rather than being due to thick mucus and sDasm.e"o The inflammation is due to mediators histamine, leukotrines, kinins, prostaglandins and chemotactic
3 6 0 S A F a m i l v P r a c t i c e f u l y 1 9 9 0 SA Huisansprakryk lulie 1990
factors released by T cells, leucocytes and mast cells.tt
Apples provoked asthma in the first case. The aroma of apple has 56 chemicals and the total apple 243 chemicals.'2 The chemicals may be inhaled whilst in the mouth, absorbed sublingually or via the gastro-intestinal tract to reach the mast cells in the bronchi.
Allen8 has provoked asthma by exposing patients to chemicals hidden in capsules, such as salicylatcs, benzoates, and amines such as
monosodium glutamate, the sodium salt of glutamic acid, a non essential amino acid. which he extracted from foods.
It is suggested that our concept of asthma should move away from the acceoted auto-immune reaction to allergens which release mediators causing the inflammatory reaction. to one where this reaction is due to irritation by chemicals in foods and inhalants. The irritable lung syndrome similar to the irritable bowel syndrome. The lung and bowel arise from the same germinal ridge
The aroma of an apple has 56 chemicals and the total apple 243 chemicals
and have the same epithelium, mucosa. submucosa. musculature and nerve supply. The common
association of irritable bowel syndrome and asthma is reported by LessoF and Borok.t3
Clinical improvement of symptoms of asthma and ulcerative colitis with histological improvemcnt of
I
\
...Asthma and Foods
in{lammatory reaction of the bowel has been described by Borok,'a the lung infl ammatory reaction improving as well, is assumed.
The significant increase in FEV 1 in all six patients after avoiding offending foods for three to twenty five months confirms this view. It is suggested that the inflammatory reaction ofthe bronchi resolved as the irritant effect of chemicals was avoided. It is further suggested that histamine, prostaglandins, benzoate, salirylate and sulphites present in foods8 themselves are the mediators that may elicit hyperresponsiveness and not necessarily released from mast cells of the patients by triggers.
Some foods contain xanthines, caffeine (coffee), theophylline (tea) and theobromine (chocolate) which are bronchodilators. Other foods contain histamine, dopami ne, acetylcholine, prostaglandins and leukotrines (honey, milk, beef, tomato and walnut) which are bronchoconstrictors.s Depending on what was eaten at the last meal, so the severity of the asthma waxes and wanes.
Anaphylactic death from foods is continually being described.rs Patient I reacted to 4 foods and 2 inhalants.
One patient reacted to 28 different inhalants, skin applications and foods." It is suggested that individual asthmatics react proportionately to the various triggers. Patient I reacted to dogs, spray'n cook, bread, apples, orange and granadilla drinks. Ifshe had apples only for a meal the attack would not be so bad. But if she ate a sandwich with egg fried in a pan with spray'n cook, apples, and washed it down with an orange drink while her dog sat on her lap she would be admitted to hospital, as happened to her one afternoon.
Ignore a cold sore for long enough, and it comes back again...
871454tR/1
36I SA Family Practice fuly 1990 SA Huisartspraktyk Julie 1990
I
It is suggested that EIA may not be produced in asthmatics if the trigger factors are identified and eliminated as shown in all 6 ofthe above cases.
Despite a large number of available treatments morbidity'u is increasing and mortalityt" has not decreased.
Warner et a1,18 in a directive of how to manage asthma, stated that, as simple pharmacological therapy is available, one should ignore foods as causing asthma as foods very rarely precipitate asthma and it is difficult to identify which foods are involved.
This policy is contrary to accepted medical practice and should itself be ignored as foods commonly trigger x51fi6x.2'3'4,s,6'8 IJsing the EP it is possible to establish which foods are associated with provoking asthma, even in children, from breast babies to teenagers, with the help of the mother.5
Acknowledgements
I wisb to express ,ny a.ppretia.ti.0n to Dr Jatnzs Ker; Professor JM Loots and Professor G Rns who ad;tised,, ancowraged. and. pet'rnined rne to dn the trial. My grateful thanhs to Mr HO Da.ehne, chi.ef bi.ohinetician, at the Spotts Reseorch Institwte who record.ed. the initial lwng functi.on and. Mr CM Schwla chief technohgist, Lung Function wnit, HF Wrwoerd. Hospital and. Unfuersity of Pretoria, who record.ed. the laner lung functi.on and. prod.und. the graphs.
References
l. fones NL, Campbell ElM. Clinical Exercise Testing. l,ondon: \4lB Saunders Coy, 1982.
2. Kaplan L The elusive link in incurable bronchial asthma - Food allergy. S Afr Med | 1967;1123.
3. Lessof MH, Wraith DG, Merrett TG, Merrett L Buisseret PD. Food
... Asthma and Foods
Allergy and Intolerance in I00 Patients - Local and Systemic Effects.
Quart I Med 1980; 195:259 7I.
4. Wilson N, Vickers H, Taylor G, Silverman M. Objective test for food sensitivity in asthmatic children:
increased bronchial activity after cola drink. Br MedJ 1982;284: L227.
5. Borok G. Childhood asthma- foods the triggerf S Afr Med I 1990;77:
269.
6. Mandell M, Scanlon MW. 5 Day Allergy Relief System. New York:
Thomas Y Crowell, 1979: l0-18.
7. Food Intolerance and Food Aversion.
A |oint Report of the Royal College of Physicians and the British Nutrition Foundation, 1983: 13 20.
8. Allen DH, Van Nunen S, Loblay R, Clarke L, Swain A. Adverse reactions to foods. Med J Australia (special supplement) 1984;, 537 -542.
9. Barnes P|, Chung I(F. Difficult asthma. (Regular Review) Br Med J 1989;299:695-8.
10. Robbins SL Ed. In: Pathologic Basis of Disease. Philadelphia-London- Toronto: WB Saunders Cov 1974:
8 0 3 4 .
ll. Rozniecki /, Kuna P. Histamine Releasing Factor in Bronchial Asthma. Allergy Today United Kingdom: Media Medica, fohn Wiley
& S o n s , 1 9 8 8 ; 2 ( 6 ) : 9 - l I .
12. Flath RA, Black DR, Guadagni DG, et al. Identification and Organoleptic Evaluation of Compounds in
Delicious Apple Essence. I Agr Food Chem1967; 15 (f ):29-35.
13. Borok G. Asthma and Foods. Paper delivered at 6th SA General Practitioners Congress. Cape Town.
14l7th March 1988
14. Borok G. l.Ilcerative Colitis and
Foods. S Afr Fam Pract 1989r l0:
468 74.
Yunginger fW, Sweeney KG, Sturner QS, et al. Fatal Food-Induced Anaphylaxis. |AMA 1988; 260:
1450 2.
Martin AJ, Landau LI, Phelan PD.
Asthma from childhood at age 2l:
the patient and his disease. Br Med / 1978;284:380 2.
British Thoracic Association. Deaths from asthma in two regions of England. Br Med J L982-285:
1 2 5 I . 5 .
Warner JO, Gotz M, Landau LI et al.
Management of asthma: a consensus statement. Arch Dis Child 1989: 64:
1065.79.
1 5 .
1 6 .
t 7
t 8 .
362 SA Family Practice /uly 1990 SA Huisartspraktyk fulie 1990
