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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The potential health risks of wheat are not always a well-founded reason for concern in western society.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The media repercussion and prevalence of food allergies are increasing.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, the strictly allergic condition related to wheat and cereals has merited less attention.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Wheat allergy can manifest in several ways. In childhood, wheat allergy can form part of food allergies,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> while in adulthood, it can be an occupational disease, as happens with baker's asthma, which is related to flour inhalation,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the less well-known but no less important wheat-dependent exercise-induced allergy. In this issue of <span class="elsevierStyleItalic">Revista Clinica Española</span>, Agulló-García et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> present their experience along with an excellent review of the topic.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Wheat-dependent exercise-induced allergy is encompassed in the group of exercise-induced food allergies.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Although the condition was described 40 years ago,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> not much is known about it due to its large clinical variability. These patients frequently present allergies to other foods, but the condition is not consistent. Patients can eat the food daily without presenting symptoms or presenting mild local symptoms (oral pruritus) without necessitating exercise. In the end, symptom onset is abrupt after the intake of the food and the performance of exercise.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The condition has been reported with numerous food items, with frequently associated allergic disease, such as allergy to some food (although often not to that food) or the presence, without exercise, of mild symptoms (oral pruritus) that do not prevent the intake of the food.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">One of the best known of these foods, which has gained importance and has given its own name to the syndrome, is wheat/gliadin, which is probably due to several of its characteristics, such as its regular (often daily) consumption, the absence of previously known allergic disease in many cases and the sudden onset of symptoms. The most commonly involved wheat allergen (but not the only one) in these symptoms is a gliadin fraction (ω-5 gliadin), unlike those involved in the pathogenesis of celiac disease (α and β gliadins, especially) but, like them, is difficult to digest. This adds another source of confusion in naming the condition, which is frequently called “gliadin allergy” or “ω-5 gliadin allergy”.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This syndrome requires a change in the previously established concepts regarding allergic reactions. It is easy to imagine an allergy as an abnormal bodily reaction to exposure to that substance to which it is allergic. We therefore tend to think that if an individual consumes a food without problem, they cannot be allergic to that food. Food-dependent exercise-induced anaphylaxis challenges this concept and requires a paradigm shift. In this case, the ingestion of the allergen/food by itself does not trigger any type of symptom, despite its regular consumption. In this case, the symptoms only appear when one or several factors (commonly known as cofactors) coincide with the ingestion of the food; in other words, the food is necessary but not sufficient for symptom onset.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The most common and best-known factor is exercise, and therefore this peculiar syndrome has been given various names, many of which refer to exercise, although this starts to get left out.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> To complicate the diagnosis, the food (in this case, one as common as wheat [e.g., bread, pasta]) can be ingested several hours before performing physical exertions, with no direct relationship with symptom onset. It is therefore difficult to determine the cause, with patient incredulity not being uncommon (“Are you really telling me that this is because of the bread I eat every day?”). The frequently severe clinical manifestations (anaphylaxis/anaphylactic shock) usually have an abrupt onset; however, the exercise intensity and duration necessary to trigger the symptoms can vary significantly and might depend on the concomitant presence of other cofactors (stress, premenstrual phase in women, previously taking anti-inflammatory agents or alcohol, etc.).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Gastrointestinal tract disorders that increase the absorption and availability of the allergen have been implicated in the pathogenesis of exercise-induced wheat-dependent allergy. There is also increased reactivity of mast cells and basophils, which react with smaller quantities of the allergen.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> It has recently been shown that the symptoms can be reproduced without the need for exercise or cofactors, although with much larger quantities of the allergen than are regularly consumed.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis of wheat-dependent exercise-induced allergy is difficult. On one hand, the gold standard consists of the placebo-controlled, double-blind tolerance test, which is rarely employed as a routine diagnostic test. On the other, the need to include physical exercise (at the necessary intensity and duration) can, along with the amount of food and other triggers, affect symptom onset and intensity.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In this specific condition, the confirmation diagnosis is even more complicated by having to include the performance of exercise and having to consider the variability of the syndrome, both in the quantity of food necessary, the exercise intensity and duration and the need for including other factors associated with the triggering of the condition. A negative test therefore cannot completely rule out the diagnosis,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the frequently severe reactions advise against or contraindicate implementing these tests.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Recognizing this condition is important because it helps prevent the onset of new episodes with a diet that is currently fairly accessible (gluten-free diet) or, in selected cases, by avoiding only the combination of the 2 factors (restricted diet only before exercising). Understanding this condition can help reduce the delay in diagnosing a potentially severe disease that is highly susceptible to occurring in an open environment. Recognizing the symptoms and administering adrenaline early (which all diagnosed patients should carry with them) can be vital.</p></span>"
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