Public, doctors alike confused about food allergies

Our grasp of food allergy science is as jumbled as a can of mixed nuts. While there are tantalizing clues on how food allergies emerge and might be prevented, misconceptions are plentiful and broad conclusions are lacking, concludes a new report by the National Academies of Sciences, Engineering and Medicine.

As a result, both the general public and medical community are confused and ill-informed about food allergies and what to do about them. Most prevention strategies and many tests used to diagnose a food allergy aren’t supported by scientific evidence and should be abandoned, the 562-page report concludes.

“We are much more in the dark than we thought,” says Virginia Stallings, a coeditor of the new report, released November 30.

While solid data are hard to come by, the report notes, estimates suggest that 12 million to 15 million Americans suffer from food allergies. Common culprits include peanuts, milk, eggs, fish, shellfish, sesame, wheat and soy.

Food allergies should be distinguished from food intolerances; the two are often confused by the public and practitioners, says Stallings, a pediatrician and research director of the nutrition center at the Children's Hospital of Philadelphia. Strictly defined food allergies, the primary focus of the report, arise from a specific immune response to even a small amount of the allergen; they produce effects such as hives, swelling, vomiting, diarrhea and, most crucially, anaphylaxis, a severe, potentially deadly allergic reaction. These effects reliably occur within two hours after every time a person ingests that food. Allergic reactions that fall outside this strict definition and food-related intolerances, such as a gastrointestinal distress after ingesting lactose, are a legitimate public health concern. But the mechanisms behind them are probably very different than the more strictly defined food allergies, as are the outcomes, says Stallings.

Anyone suspecting a food allergy should see a specialist. If medical history and preliminary results hint at problems, then the gold standard diagnostic test should be applied: the oral food challenge. This test exposes an individual to small amounts of the potentially offending food while under supervision. Doctors and others in health care should abandon many unproven tests, such as ones that analyze gastric juices or measure skin’s electrical resistance, the report concludes.

Regarding prevention, research has borne a little fruit: The authors recommend that parents should give infants foods that contain potential allergens. This recommendation is largely based on peanut allergy research suggesting early exposure is better than late (SN: 3/21/2015, p. 15). There’s little to no evidence supporting virtually all other behaviors thought to prevent food allergies, such as taking vitamin D supplements, or women avoiding allergens while pregnant or breastfeeding.

While additional rigorous long-term studies are needed to better understand why food allergies arise, the report addresses many issues that society can confront in the meantime. Industry needs to develop a low-dose (0.075 milligrams) epinephrine injector to treat infants who experience food allergy anaphylaxis; the U.S. Food and Drug Administration, Department of Agriculture and the food manufacturing industry need to revamp food labeling so it reflects allergy risks; and relevant agencies should establish consistent guidelines for schools and airplanes that include first-aid training and on-site epinephrine supplies.

“This report is mammoth and very impressive,” says Anita Kozyrskyj, whose research focuses on the infant gut microbiome. Kozyrskyj, of the University of Alberta in Canada, presented research to the reports’ authors while they were gathering evidence. She says the report identifies issues that can help guide the research community. But its real value is in the recommendations for parents, schools, caregivers and health care providers who are dealing with food allergies in the here and now.