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RANJANI RAMANUJAM1*,ALESSANDRO FIOCCHI2, WILLIAM SMITH3 *Corresponding author 1. Senior Medical Writer, Sprim India, No. 10, 1st A Main, S.T. Bed Layout, IV Block, Koramangala, Bangalore 560034, India 2. Pediatric Allergy Department, Pediatric Hospital Bambino Gesù, 20142, P.zza S. Onofrio 4, Rome, 3. Clinical Immunology and Allergy Department, The Royal Adelaide Hospital, North Terrace Adelaide 5000, South Australia Ranjani Ramanujam Lupin allergy: Is it really a cause for concern?

KEYWORDS: Lupin, functional food, allergy, β-conglutin.

Lupin is a commonly used in the bakery industry in several regions of the world since the last Abstract few years. Allergic reaction with lupin in the general population is not clearly known. It appears to be low and probably depends on dietary habits and geographical differences, likely as a result of exposure. Most cases have been reported from Europe. Additionally, sensitisation to lupin flour is significantly more frequent compared to clinical manifestations. Lupin allergy has been observed usually in individuals with known allergy because of the similarity of its key , β-conglutin to that of the latter, Ara h 1. Cases of primary lupin allergy have also been reported occasionally. Appropriate product labelling by manufacturers and awareness among physicians and general public are required for overcoming the challenges associated with Lupin allergy.

INTRODUCTION a wheat- or soya-substitute. Lupin products are found in various bakery and other food products like biscuits, pasta, Lupin is a member of the Legume which is the second pizza, chocolate spreads, sauces, soups, pastes, sausages, largest family of seed . Peanut and soy also belong and milk and soy substitutes (3). Although lupin has been to the same family (1). The Lupinus comprises of tested for wine clarifi cation, its use is still not approved. In approximately 200 to 600 ; however, only a few of Asian countries such as and Indonesia, lupin is used as them have been domesticated (2). The four species of lupin an ingredient in traditional fermented foods like tempe and used in foods are (white lupin, Mediterranean miso (7). countries), (yellow lupin, Central Europe), Lupin seeds are rich in (>35%) and dietary fi bre (blue lupin, Australia) and (25-30%), and very low in lipids (8-10%), and carbohydrates (pink lupin or Andean lupin, South America)(3). However, the (5, 10). Lupinus albus is an important source of proteins for last one has not yet attracted much of research interest (4). human beings: its seed is very rich in protein content, having White lupin is predominantly used in the food industry, while a biological value of 91% of egg proteins. Additionally, blue and yellow lupin are used for animal feed (5). these seeds have a higher essential amino acid index (EAAI) Lupin can be cultivated in all climates, making it an and protein effi ciency ratio (PER), based on lysine and attractive crop (6). It is cultivated globally not only for tyrosine availability, compared to those of L. luteus and L. livestock and poultry feed but also for fertilizing the soil(1). angustifolius (9). Australia is the largest producer of lupin in the world, Consumption of lupin seeds is associated with various health followed by Europe. The predominant European countries benefi ts (2, 11). The health benefi ts of lupin-enriched foods cultivating lupin are Germany, France, and Italy include increased satiety and reduced energy intake (12), (7). decreased blood glucose level (13), hypolipidemic effect It has been increasingly used as a functional food or (14, 15) and antihypertensive properties (16, 17). Higher food ingredient because of its nutritional properties satiety and lower energy intake is attributed to high protein such as high content of protein, fibre, oligosaccharides and fi bre content of Lupin that affects appetite-regulating and phenolic compounds (8), as well as its favourable hormone called ghrelin, which is released from the stomach technological properties (9). Inclusion of lupin in wheat and acts on the central nervous system to stimulate food flour was first permitted in the United Kingdom in 1996, in intake. Ghrelin secretion infl uences post-meal satiety and France at the end of 1997 and in Australia in 2001 to add subsequent energy intake (12).The addition of lupin fl our to protein and fibre and improve food texture (1, 7). processed foods resulted in higher post-meal satiety of up to Lupin products available include toasted and non-toasted 4.5 h and reduced energy intake of about 15% compared to lupin fl our, granulates, fi bre, oil and protein concentrates the test day (18). from non-defatted seeds (7). The seeds of L. albus and L. Lupin may be considered an interesting food ingredient for mutabilis are commonly used and referred to as ‘lupini appetite regulation (12). It contains several phytochemicals ’. Lupin fl our is manufactured on a large-scale as like oligosaccharides, phytic acid, tannins and saponins,

10 Agro FOOD Industry Hi Tech - vol. 27(1) - January/February 2016 which help in reducing the blood glucose levels, when added to carbohydrate-rich foods such as bread (13). Lupin seeds inhibit diet-induced hypercholesterolemia by decreasing in plasma total cholesterol, VLDL and LDL-cholesterol, increasing hepatic LDL receptor synthesis and HMG-CoA reductase activity, and stimulating intestinal bile acid reabsorption (14, 15). The composition of white lupin oil appears very promising, because it is according to standard dietary recommendations for CVD prevention (>50% oleic acid, <18% linoleic acid, and> 7% α-linolenic acid) (4). Hall et al. Table 1. Self-reported lifetime prevalence of various food allergies globally as well demonstrated about a decade ago, that as in Europe. consumption foods fortified with lupin caused a small but significant decrease in total and LDL-C (13). In another study by Sirtori et al., it was similar to all other allergic diseases (23). Self-reported lifetime observed that lupin protein was more effective than pea prevalence of various food allergies globally (24) as well protein in decreasing plasma cholesterol levels (15). as in Europe (25) based on the results of two metaanalyses Studies have shown that lupin has antihypertensive effects are shown in Table 1. Allergy to cow’s milk seemed to be (16, 17). It normalises the decreased vasoconstriction, the most common, both worldwide as well as in Europe with improves the impaired endothelium-dependent prevalence rates of up to 17% and 6%respectively. vasorelaxation (16) and inhibits angiotensin converting Australia has one of the highest prevalence of allergic enzyme (ACE) activity (17). Nowicka et al. demonstrated disorders in the developed world. While the prevalence of a significant reduction in blood pressure in hypertensive allergic rhinitis, asthma and atopic eczema seem to have subjects, with a stronger effect on those with milder reached a plateau, food allergy seems to have increased. hypertension (19). Similarly, two more recent randomised In a single clinic study, there was a 12-fold increase in food controlled studies by Lee et al. and Belski et al. showed that allergy from 11 to 138 patients (20.0% to 57.5% of children lupin flour enriched bread caused a significant decrease in seen) from 1995 to 2006 (26). BP when compared to control bread (20, 21). In Australia, the HealthNuts Investigators conducted a study to To summarise, studies have demonstrated that lupin measure the prevalence of common immunoglobulin-E (IgE)- proteins play key roles on crucial physiological parameters, mediated childhood food allergies in a population-based such as plasma glucose and lipid concentrations, and sample of 12-month-old infants (n=2848) (27). The prevalence blood pressure levels. All these parameters were previously of any sensitisation to various food substances and oral considered to be affected in the developed countries, challenge-proven food allergies are shown in table 2 (27). Self- but it seems to be significantly affecting the developing reported cases of allergy are overestimated when compared countries (4). to that proven by oral challenge. However, when we observe the data presented in Tables 1 and 2, this does not seem to be the case. Probably, a clinical trial subjecting participants LUPIN ALLERGY who self-report of allergies to sensitisation and oral challenge will help clarify this. are implicated to commonly cause allergies. This Legumes are dicotyledonous plants comprising of three is especially the case for peanut and to a lesser extent, families: Mimosaceae, Caesalpiniaceae and Fabacea or . Allergy to lupin has also been observed (1). Papilionaceae (28). Those belonging to the family Lupin allergy has been reported mostly in individuals who have contributed to the overall increase in the prevalence of are allergic to other legumes, especially peanut. Hefle et al. food allergy. This is probably because these are rich in protein reported the first case of lupin allergy in 1994 in a girl with content, and the preferred source world-wide leading to their known peanut allergy who presented with urticaria and increased consumption globally (29). The legumes implicated angioedema after consuming pasta fortified with sweet lupin to cause allergy include lentil, chick-pea, pea, peanut, , seed flour (22). There are several health benefits of lupin regardless of the problem of allergy. Therefore, its use in the food industry has increased in the recent times. This may be a cause for the apparent rise in the reporting of allergies (9).

Prevalence and trend Food and legume allergy In the developed countries, food allergies affect about 8% of young children and 2% of Table 2. Sensitisation to food substances vs. oral challenge proven allergy among Australian infants (n=2848). adults, and these rates seem to be increasing

Agro FOOD Industry Hi Tech - vol. 27(1) - January/February 2016 11 soy and lupin (28). To our knowledge, global prevalence rates of legume allergy are not available because the prevalence rates vary with the geographic regions. This is because of the difference in the cultural and dietary habits, where an increased consumption of a particular legume may result in sensitization against it. Genetic factors and exposure to new allergenic proteins early in life may also contribute to this geographic variation (29). Various studies have shown that prevalence of food allergies vary across geographic regions. While peanut allergy is higher in Europe and USA (prevalence rate of 0.6-1%), soy flour allergy is more common in Japan (29). In Spain and India, chickpea allergy is more prevalent (30, 31) whereas in Spain, lentil allergy is common in Spain (30). Table 3. Summary of studies on Lupin sensitization vs. oral challenge reactivity. Lupin allergy The prevalence of lupin allergy has been reported to increase in parallel with its increasing a recently published study, Bansal et al. report that in their consumption. However, the frequency of lupin-allergic reaction practice they observed lupin sensitisation in approximately in the general population is not clearly known, but it appears to one-fifth of patients with peanut allergy. However, only a few be low (8) and probably depends on the dietary habits as well presented with clinically symptomatic allergies, which were as the geographical differences (7). Moneret-Vautrin reported mostly mild and localised in nature (38). that lupin was the fourth most common anaphylaxis-eliciting In another study by Bernhisel-Broadbent and Sampson, results foods in 2002, after , nuts and shellfish, according to the of oral food challenges showed that clinically important cross- Allergy Vigilance Network in France (32). reactivity to legumes including peanut, soybean, green bean, Several studies assessed sensitisation as well as clinical pea, and lima bean in children is very rare. Based on their reactivity to lupin flour (Table 3) (3, 11, 33-36). Sensitisation study findings, they suggested that clinical hypersensitivity was determined in these studies by skin prick test and/or to one legume did not warrant dietary elimination of all serum IgE positivity, while clinical reactivity was assessed by legumes, and diets with prolonged food restriction should not oral challenge test. While some studies showed sensitisation be recommended based on results of positive skin prick tests to be more common than clinical reactivity (3, 6, 34, 35), (39). In a Spanish study, the authors concluded similarly, and others, surprisingly demonstrated contradictory findings stated that the decision to eliminate any legume from the (11, 33, 36). Additionally, as shown in table 3, about 16- diet should be based on a positive oral food challenge (28). 63% of subjects who are allergic to peanuts present with symptomatic lupin allergy. Clinical characteristics Clinical presentation While lupin allergy is predominantly observed in those In theory, individuals with previous legume allergy have a with peanut allergy, primary sensitisation has also been higher risk of development of lupin sensitization, but the encountered. In a study by Gayraud et al., primary clinical relevance of this has not been established (40). sensitisation to lupin was observed in 3.7% of the 1,422 patients On the contrary, clinically relevant lupin allergy is often with current atopic disease and 1.8% of the 226 patients with observed in individuals without a history of atopy or food latent atopy. Based on these findings, the authors opine that allergies. Surprisingly, lupin allergy is observed more in a the incidence of primary allergy to lupin might increase in the country where lupin is not traditionally used, implying that near future in Europe (37). short-term, moderate use of lupin can result in serious allergic reactions (41). Cross-reactivity among legumes and its clinical relevance Asymptomatic sensitisation is most frequent, but Serological cross-reactivity between members of the legume occasionally, clinical manifestations of allergy can family has been observed frequently; however, it does not also present (38). Sensitisation (1, 7) as well as clinical always translate to clinically symptomatic allergies (8). In a manifestations of lupin allergy can occur after ingestion as large, prospective study carried out in France and Belgium by well as inhalation. Symptoms of lupin allergy are similar to the Allergy Vigilance Networks, in both children and adults, those observed with other food or inhalant and cross-reactivity with lupin was found to be more frequent in can be varied in severity (7, 38). Most individuals may only those with peanut allergy (17.1% and 14.6% respectively) and experience a mild reaction; however some patients will current atopic disease (2.5% and 3.7% respectively) (37). In present more severe symptoms (7).

12 Agro FOOD Industry Hi Tech - vol. 27(1) - January/February 2016 Signs and symptoms that have been reported vary to eliminate the allergenic potency of lupin proteins: from urticaria, atopic dermatitis, facial oedema, boiling in an autoclave at 121°C (1.2 bar) for 20 min rhinoconjunctivitis, oral allergy syndrome, mucosal significantly reduces IgE binding and at 138°C (2.6 bar) for erythema, angioedema, asthma, throat tingling, cough, 30 min abolished the lupin allergenicity (55). Instantaneous abdominal symptoms, to some rare cases of anaphylaxis controlled pressure drop treatmentis a novel and highly (7). Individuals with known food allergies usually carry controlled process used in food technology, in which steam antihistamines with them, and they are more careful pressure (up to 8 bar) with heat (up to 170°C) are combined about food consumption; therefore, symptoms may be for a short time of up to 3 min. This procedure has been mild in them. On the contrary, in individuals with primary shown to reduce the allergenicity of lupin (54). However, sensitization, the allergic symptoms are severe, probably this study did not assess the effect of autoclaving on the because of lack of awareness of allergy. solubility of lupin proteins. Cabanillas et al. evaluated the solubility of proteins from roasted and autoclaved roasted Allergy eliciting dose peanut (1.18 and 2.56 atm, 15 and 30 min). In the soluble Very few studies have reported the allergy-eliciting dose of fractions, there was a reduction in the overall level of intact lupin. Further, there is a significant difference among these proteins following autoclave treatments compared with doses reported, and therefore no conclusion can be drawn insoluble fractions. Further, a decrease in the relative Ara h on the allergenic dose. In a study by Peeters et al. conducted 1, Ara h 2 and Ara h 3 levels was observed in autoclaved on eight lupin-allergic patients, no-observed adverse effect roasted peanut samples with increased pressure and time, level was 0.1 mg lupin flour for subjective symptoms and 1 mg in the soluble fraction compared to the insoluble fraction, for objective symptoms, of whom three patients experienced and these results were more evident in Ara h 1 than Ara h only subjective responses at the highest dose of 3000 mg (6). 2 and Ara h 3 proteins. Therefore, the relative level of Ara The lowest eliciting dose described by Moneret-Vautrin et al. h 1 was higher in the insoluble versus the soluble fraction of was 265 mg of lupin flour which induced abdominal pain and autoclaved roasted peanut. Despite these observations, asthma in patients who were allergic to peanuts (32). Peeters there was a marked decrease in the recognition of all three et al. studied on six patients and reported that the eliciting proteins in autoclaved roasted peanut at 2.56 atm, 30 min dose was 1 mg or less for subjective symptoms and 300 mg for even in the insoluble fractions (56). Therefore, we can infer objective symptoms (1). In a study by Fiocchi et al., positive that although there may be differences in the solubility clinical reactions were observed in two peanut-allergic of proteins after autoclaving, overall, there is a decrease children, on consumption of 50 mg and 1.6 g of lupin proteins, in their levels, which in turn translates to reduction in their respectively (34). According to the recently published VITAL allergenicity. There is a need to evaluate the effects of (Voluntary Incidental Trace Allergen Labeling) program of autoclaving on the solubility of proteins and effects on The Allergen Bureau of Australia and (ABA), the nutritional value of lupin. reference allergenic dose of lupin protein is 4 mg, while that for peanut was much lower (0.2 mg of peanut protein) (42). Diagnosis Clinical examination and a proper history taking are the Pathogenesis cornerstone of diagnosis of any condition including that Three possible forms of clinical allergy to lupin have been of lupin allergy. However, asymptomatic sensitization and reported: a) the most frequent is primary allergy to peanut further, confirmation of clinical suspicion of allergy can be with cross-reactivity to lupin, b) primary allergy to lupin, c) done using skin prick test and specific IgE estimation (38). primary allergy by inhalation of lupin pollen or flour (often Cross-reactivity can also be diagnosed by these tests. While occupational) (37). skin prick test is an in vivo test, in vitro tests include ELISA-IgE As already described in the previous sections, lupin and immunoblotting (57, 58). sensitization has been observed mainly in patients with allergies to other legumes, especially peanut and those with Management and Prevention atopy (38). However, isolated lupin allergy can also occur. On the basis of a positive skin prick test, stopping an Vicilins or 7S globulins are the most important storage individual from ingesting a tolerant food is not required; proteins in the legume seeds (43, 44), including lupin.1 Four in fact, the ability to ingest the food is itself the proof of vicilins, including two major fractions (α- and β-conglutins) tolerance, according to Sicherer and Sampson (59). and two minor fractions (γ- and δ-conglutins) have been However, if there are clinical manifestations of allergy, identified (45). then to the first step is to stop exposure to the allergen. β-conglutin, one of the major vicilins and also known as Lup An antihistaminic agent should be administered. In case an 1 is considered as the major lupin allergen. Additionally, of anaphylaxis, adrenaline either intramuscularly or it has a sequence similar to the peanut vicilin, Ara h 1, which intravenously, intravenous corticosteroids and antihistamines is most commonly implicated for allergenicity (36, 45, 46). have to be administered. β-conglutin is currently the only lupin protein which has been However, lupin allergy can be prevented if the following included in the list of allergens from plant source.No other measures are taken: lupin protein has been included in the list (47). -- Physicians and public should be made aware of lupin There have been varied reports on the effects of heat on the flour as a potential allergen (38). allerginicity to legumes (48-53). -- Food-service workers and individuals with known allergy Lupin allergens are relatively heat stable and this further should be educated on the practices of the food-service complicates the problem of lupin allergy, where microwave industry especially regarding “hidden” allergens (60). cooking, boiling and extrusion cooking produce minimal -- Patients with a known allergy to peanuts should be changes on IgE binding to lupin proteins (54). advised to avoid all products containing lupin until they However, a combination of heat and pressure is required can be specifically tested (60).

Agro FOOD Industry Hi Tech - vol. 27(1) - January/February 2016 13 -- Lupin, when used in a food product, should be included 11. Smith, P.M.C., Goggin, D.E., Mir, G.A., et al. Characterisation of in the list of ingredients in the packaging (38). allergenic proteins in lupin seeds and the relationship between -- In 2006, the European Union included lupin among peanut and lupin allergens. In J.A. Palta and J.B. Berger allergenic foods for which labelling is mandatory (61). (eds). ‘Lupins for Health and Wealth’ Proceedings of the 12th International Lupin Conference, 14-18 Sept. 2008, Fremantle, Similarly, in countries where the use of lupin is more, . International Lupin Association, Canterbury, introduction of such legislations may be prudent. New Zealand; pp.459-462 (2008). 12. Lee, Y.P., Mori, T.A., Sipsas, S., et al. “Lupin-enriched bread increases satiety and reduces energy intake acutely” Am J Clin SUMMARY AND CONCLUSIONS Nutr, 84, 975-80 (2006). 13. Hall, R.S., Thomas, S.J., Johnson, S.K. “Australian sweet lupin Lupin is a legume, which is often used in the bakery flour addition reduces the glycaemic index of a white bread industry, especially in European countries since the last few breakfast without affecting palatability in healthy human years. Although similar to other legumes, lupin has been volunteers”, Asia Pac J Clin Nutr, 14, 91-7 (2005). implicated to cause allergy, clinical reactivity to lupin 14. Martins, J.M., Riottot, M., de Abreu, M.C., et al. “Cholesterol- lowering effects of dietary blue lupin (Lupinus angustifolius) in flour is significantly less when compared to sensitisation. intact and ileorectal anastomosed pigs”, J Lipid Res, 46, 1539-47 Lupin sensitisation occurs in approximately one-fifth of (2005). patients with peanut allergy, but most present with mild 15. Sirtori, C.R., Lovati, M.R., Manzoni, C., et al. “Proteins of white and localised clinical symptoms. Although serological lupin seed, a naturally -poor legume, reduce cross-reactivity between members of the legume family cholesterolemia in rats and increase LDL receptor activity in occurs frequently, it does not always translate to clinically HepG2 cells”, J Nutr, 134, 18-23 (2004). symptomatic allergies. 16. Pilvi, T.K., Jauhiainen, T., Cheng, Z.J., et al. “Lupin protein Additionally, clinical hypersensitivity to one legume does not attenuates the development of hypertension and normalises the warrant dietary elimination of all legumes, and diets with vascular function of NaCl-loaded Goto-Kakizaki rats”, J Physiol prolonged food restriction should not be recommended Pharmacol, 57, 167-76 (2006). 17. Yoshie-Stark, Y., Bez, J., Wada, Y., et al. “Functional properties, based on positive results of skin prick tests, but on a positive lipoxygenase activity, and health aspects of Lupinusalbus oral food challenge. 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