What are food allergens and food sensitivities? This is an area of heightened awareness today. While there is much we know about allergens, there is still much we need to learn. What we do know is that there is no cure for food allergies; strict avoidance is the only way to prevent a reaction.
There are more than 15 million Americans who are allergic to one or more food products included in the "Big 8"—the most common food allergens in the United States—which we will cover in more detail later. In the food industry, we must be especially aware of allergies and the foods and components of food that cause allergic reactions. Each year there are 30,000 allergy-related emergency room visits and 150 deaths attributed to food allergies. For your clients, food allergies are truly life and death!
One in 25 individuals, or 4% of the population, have food allergies. As a point of comparison, 8% of the U.S. population has diabetes, a much more visible concern.
For our purposes, we'll define food as a substance that may be processed, semi-processed, or raw and intended for consumption. This includes additives, drinks, gums, and supplements.
A food allergy is an adverse health effect arising from a specific immune response that occurs when a person comes into contact with a food to which he or she has previously been sensitized. However, this term is broadening to encompass any immunologic reaction to a component of a food that results in symptoms. Food allergens are chemical components of food (usually proteins) that are recognized to elicit an immune reaction.
Our immune systems exist to prevent diseases caused by viruses, bacteria, or toxins. A food allergy occurs when the body reacts similarly to an allergen. We call this initial contact sensitization. Once someone has been sensitized, the body's immunologic defense will kick in, resulting in an allergic reaction with symptoms.
Oral Allergy Syndrome, also known as pollen-food syndrome, is a condition that can affect people who also have hay fever. It manifests as an itchy or scratchy feeling in the mouth. It is caused by cross-reacting allergens in pollen, raw fruits, vegetables, and some tree nuts. The cross-reactivity occurs when the body's immune system recognizes proteins similar to those to which the body has been sensitized in these foods and an allergic response occurs. Onset of this syndrome is most common among older children, teens, and young adults, and not typically in young children.
The only time you would ever hear an allergy expert tell you cooking a food neutralizes the allergens in it may be in the case of Oral Allergy Syndrome. It has been found that heating the food alters the proteins enough in the offending fruits and vegetables to prevent the immune system from recognizing them and causing an allergic response.
Most common examples of pollens that may be present in fruits and vegetables that can trigger Oral Allergy Syndrome are:
FPIES is a food allergy affecting the gastrointestinal tract. Symptoms of FPIES include profound vomiting, diarrhea, and dehydration. These symptoms can lead to severe lethargy, changes in body temperature, and altered blood pressure.
This is a serious condition that often affects very young children and can require hospitalization. The American College of Allergy, Asthma & Immunology says that most children outgrow FPIES by age 3 or 4.
How does FPIES come to light? According to the FPIES Foundation, infants or children with FPIES might come to medical attention when severe, repetitive vomiting or diarrhea follows ingestion of a food. A typical timeframe is 2-3 hours after ingestion. Findings may include low blood pressure, dehydration, lethargy, and pale of blue coloration. According to the FPIES Foundation, "Many infants who are eventually diagnosed with FPIES are initially suspected to have a severe infection or sepsis."
An infant with FPIES who continues to consume the problem food over time may experience poor growth, and may develop symptoms that look like a total-body infection. Common triggers are infant formula—including soy or dairy, rice, oats, chicken, turkey, or fish.
A component of treatment for FPIES may be hypoallergenic formula, e.g., a casein hydrolysate-based formula, and substation of yellow fruits and vegetables for cereal.
Any type of food reaction, regardless of severity or type, is considered a food sensitivity. Based on its severity, the classification is then further divided into:
An intolerance is still an adverse reaction, but it is not caused by an immune system response, such as with an allergen. In this case, the body is not capable of digesting, absorbing or metabolizing the food or a component of a food.
U.S. News & World Report recently covered the new trend in testing for food sensitivities (not allergens). They report that sensitivities caused by enzyme deficiencies, histamines, tyramine, or sulfites can be identified by testing. However, many other "sensitivity" tests have not been validated.
An intolerance can be diagnosed via blood tests:
While more than 160 foods can cause allergic reactions, U.S. law defines 8 as most common. This list is called the Big 8:
These eight foods account for approximately 90% of all food allergies in the U.S. However, according to the CDC, more than 220 other foods have been documented as causing the remaining 10% of allergic reactions.
Some of these other foods include molluscan shellfish (such as clams, mussels, and oysters), strawberries, mustard, sesame seeds, celery, black pepper, MSG, and stone fruit (any fruits with a pit, like cherries, avocados, and peaches).
There is ongoing discussion in scientific and policy communities about adding to the Big 8 list.
Our counterparts in Canada and the UK include many of the products mentioned above to their mandatory labeling and acknowledgment lists. They include the United States' "Big 8" plus:
Diagnosing a food sensitivity, intolerance, or allergy is a lengthy process for most individuals. There are multiple processes and tests one must go through in order to be officially diagnosed with any of these allergies.
Initially, a thorough history and physical evaluation must be performed by a licensed allergist. This is followed by these four components of the diagnostic process: daily food journal, skin tests, blood tests, and double-blind placebo controlled food challenge.
Daily Food Journal - This is the most important tool in the initial food allergy diagnosis. It acquaints both physician and patient with current diet and any underlying symptoms. It will help the patient with education, understanding, and implementing safe practices while grocery shopping and dining out, like reading food labels. The daily food journal allows a physician to truly understand what the patient is ingesting and the effect it has on the body. Without this, it's impossible to begin the process.
Skin Tests - There are two types of skin tests performed in allergy diagnosis:
These tests may hurt slightly, and there may be itchiness and discomfort where the allergen was placed.
Blood Tests - There are two blood tests used to detect food allergies. The tests measure Immunoglobulin E (IgE) levels in the patient's blood.
A Double Blind Placebo Controlled Food Challenge (DBPCFC) is one technique for diagnosing a food allergy. Double Blind Placebo refers to an investigative technique in which both the subject and the physicians are unaware of what substance is being provided. A suspect food is mixed in with another food so its identity is disguised. Alternately, the food may be provided in capsule form. This "blind" approach prevents both the patient and the physician from responding based on familiarity of a food or an expectation of adverse effects.
This test is performed in a medical office for safety, and the patient is monitored carefully for reactions.
According to The Cleveland Clinic, "Someone with a history of severe reactions cannot participate in a food challenge test. In addition, multiple food allergies are difficult to evaluate with this test."
The DBPCFC test is an effective, but expensive, method for confirm or ruling out specific food allergies.
Cross contact occurs when one food comes into contact with another food and the proteins mix. Usually it is such a small, trace amount that it is not visible, making it very dangerous from a food-allergic person's perspective.
The term "Cross contamination" is often used in foodservice establishments and more commonly refers to foodborne illness. However, similar principles apply. In either case, surfaces or foods that have been in contact with allergens should never come into contact with foods being served to an allergic individual.
Every three minutes, a food-allergic reaction sends someone to the emergency room.
Food allergies are the most common cause of anaphylaxis in U.S. emergency rooms, accounting for 30% of all cases.
Experts estimate that there are 50,000 anaphylactic reactions, 2,000 hospitalizations, and 150 deaths annually from food allergies.
Once a diagnosis is made, the patient and the patient's family are inundated with a daunting amount of information. The patient's diet changes completely. Suddenly, he or she must read every food label prior to eating anything. Cooking at home becomes more challenging, as the cook must proceed as if the entire house has an allergy. Everyone around the patient must be educated about the necessary precautions and risk factors.
Allergen awareness, tolerance, and sensitivity must be built into how we go about our daily lives. For those individuals who live with food allergies, everyday events become much more complex. Take for instance:
Training, education, and proper standard operating procedures can make all the difference. It is not just an organization's reputation on the line; it is a matter of life or death to those with food allergies.
Recent cases involving everything from packaged cereal bars and grocery store cookies to burger bars and Mexican restaurants have resulted in the deaths of children as young as 11 years old to full-grown adults.
Foodservice operators may be held liable in such cases. In a landmark case in the UK, Mohammed Khalique Zaman, the owner of several award-winning establishments, was charged with manslaughter by gross negligence following the death of 38 year-old Paul Wilson, who had eaten takeout from one of Zaman's restaurants. Wilson, who was peanut-allergic, ate a curry dish in which peanuts had been used instead of almonds without any notification to customers of the substitution.
In another important case, Amanda Thompson, a British midwife and mother of two died while vacationing in Greece. She had made her allergies to eggs, milk, and apples known to both the travel agent and the hotel at which the incident occurred. During a meal specially prepared for her needs, she began to experience tingling in her tongue after eating sorbet. She returned to her hotel room, collapsed, and never regained consciousness.
A Greek pathologist ruled her death heart failure due to natural causes, but Thompson's family believed it to be the result of anaphylactic shock brought on by an ingredient in the sorbet, which was confirmed over a year later by a British pathologist.
The delay in formally declaring Thompson's death a case of food allergy-induced anaphylaxis demonstrates the difficulty in reporting and documenting food allergies.
Allergen sensitivity can occur at any time in someone's life, in response to seemingly unrelated events.
Canadian research has found that food allergies can be temporarily passed to others through blood transfusion. Such cases are extremely rare, but could result in patients developing potentially fatal anaphylactic reactions to previously tolerated foods. The research began after an eight year-old boy with no history of allergies undergoing chemotherapy and blood product support had an allergic reaction after eating salmon. Four days later he experienced a reaction to peanuts. Investigators traced the source to just one donor who had these known food allergies, with an acute reaction to peanuts, tree nuts, shellfish, and all other fish, including salmon. Researchers said food allergies could be passed on through the transfer of IgE in blood platelets, although instances are extremely uncommon.
As reported by The Telegraph, Dr. Julia Upton of The Hospital for Sick Children in Toronto said, "It is very unusual to identify someone who experienced passive transfer of allergy from blood products." Importantly, this condition has an excellent prognosis and typically resolves within a few months. Upton also said allergies were too common to rule out transfusions from those who suffer from them.
A gentleman living in the Southeast experienced an allergic reaction two to three hours after consuming red meat. This was unusual, since most allergic reactions occur within an hour after consumption. After visiting an immunologist, it was discovered that through a tick bite, he had developed an allergy to alpha-gal, a carbohydrate found in red meat.
In these cases, the body is sensitized by a bite from the Lone Star tick, creating alpha-gal-specific IgE antibodies. The body then reacts to alpha-gal in red meat by releasing histamine, causing sneezing, itchy eyes, runny nose, and other symptoms. Fatty meats in particular have a higher concentration of alpha-gal and the fat causes the reaction to be delayed.
Viaskin Patches - DBV Technologies is developing Viaskin®, a proprietary, patented technology for administering an allergen to intact skin while avoiding transfer to the blood, and thus lowering the risk of a systemic, allergic reaction in the event of accidental exposure.
Hypoallergenic Peanuts - Scientists at North Carolina A&T University have found a way to reduce the allergen Ara h1 to virtually undetectable levels and allergen Ara h2 by up to 98% without affecting the taste.
This clinical trial investigated how best to prevent peanut allergy. 640 children, age 4 to 11 months, identified as high risk for peanut allergy via an existing egg allergy and/or severe eczema were chosen for the study, and split into two groups and followed through the age of five.
One group followed a course of consumption equivalent to six grams of peanut protein per week. The second group strictly avoided peanut-containing foods throughout the study.
The study found that the consumption group had a 3% occurrence of peanut allergy, while the avoidance group had a 17% occurrence. The trial's conclusion was that consumption prevents subsequent development of the allergy in high-risk infants.
J.J. Levenstein, MD, explains on the peanutallergy.org website, "Parents of high risk children should feel more confident, and perhaps even elated, that they can reduce their child's potential risk of allergy to peanuts through early introduction."
In addition, new research indicates that consumption of fish oil supplements during pregnancy can reduce a child's risk of developing allergies. Likewise, consumption of probiotics during pregnancy can reduce the risk of a child developing eczema.
Food allergies affect everyone. Whether it concerns the safety of school children, or ensuring that restaurant guests can dine with peace of mind, it is important to understand what food allergies are, which foods can trigger them, the severity of food-allergic reactions, and how to effectively prevent them from occurring.
As foodservice operators, understanding food allergies and how to address them with sensitivity is essential—for your guests' safety, comfort, and the success of your organization.
We'd love to hear from you! Contact:
Associate Brand Manager
Michael Foods, Inc.
If you would like to submit your evaluation and comments to the Commission on Dietetic Registration, you may do so at http://www.cdrnet.org.