The psychosocial impact of food allergy and food hypersensitivity in children, adolescents and their families: a review

Using 'may contain' labelling to inform food choice: a qualitative study of nut allergic consumers

Background

Precautionary 'may contain' warnings are used to indicate possible allergen contamination. Neither food safety nor foods labelling legislation address this issue. The aim of this study is to understand how peanut and nut allergic adults interpret 'may contain' labelling and how they use this information when purchasing food.

Methods

Qualitative methods were used to explore both behaviour and attitudes. The behaviour and 'thinking aloud' of 32 participants were recorded during their normal food shop. A semi-structured interview also explored participants' views about 13 potentially problematic packaged foods. Transcribed data from these tasks were analysed to explore the interpretation of 'may contain' labelling and how this influenced food choice decisions.

Results

Peanut and nut allergic individuals adopt a complex range of responses and strategies to interpret 'may contain' labelling. Many claimed such labelling was not credible or desirable; many ignored it whilst some found it helpful and avoided products with all such labelling. Interpretation and consequent decisions were not only based on the detail of the labelling but also on external factors such as the nature of the product, the perceived trustworthiness of the producer and on the previous experience of the nut allergic individual.

Conclusions

'May contain' labelling was interpreted in the light of judgements about the product, producer and previous personal experience. It is vital that these interpretation strategies are taken into account by those responsible for labelling itself and for the provision of advice to nut allergic individuals. Suggestions to improve labelling and advice to the allergic individual are considered.

Oral desensitization for food hypersensitivity

Food allergy has become an increasingly prevalent international health problem. Allergic reactions can result in life-threatening anaphylaxis in a short period of time, so the current standard of care dictates strict avoidance of suspected trigger foods and accessibility to injectable epinephrine. Intervention at the time of exposure is considered a rescue therapy rather than a disease-modifying treatment. Investigators have been studying allergen immunotherapy to promote induction of oral tolerance. This article examines the mechanisms of oral tolerance and the breakdown that leads to food allergy, as well as the history and current state of oral and sublingual immunotherapy development.

How do peanut and nut-allergic consumers use information on the packaging to avoid allergens?

BACKGROUND

Recent legislation has sought to improve the information printed on packaged foods relevant to the safety of food allergic consumers. We aimed to understand the complex risk assessment decisions made by peanut and nut-allergic adults when purchasing food, with particular reference to use of printed package information.

METHODS

The behaviour and 'thinking aloud' of 32 participants were recorded during their normal food shop, followed by a semi-structured interview. During the interview they were given 13 potentially problematic packaged foods, and asked if they would purchase the product and what their reasons were. Transcribed data from the shop, interview and 13-product task were analysed to explore use of allergy advice boxes, ingredients lists and other packaging information.

RESULTS

Some participants used the ingredients list as their primary check for allergens, but most used the allergy advice box. Package-based information was generally considered reliable, but some supermarket and brand labels were trusted more than others. Images and product names were used to draw inferences about the presence of nuts. A number of improvements were suggested by participants, particularly a request for more 'nut free' labelling.

CONCLUSIONS

Food labels were used in conjunction with nonpacket-based strategies (e.g. previous experience) to make choices. External factors (e.g. trust of manufacturer) informed interpretation of and confidence in labels. Images and product names, not intended by manufacturers as an allergen risk assessment aid, were also used to inform choices.

Depression is more common in girls with nonatopic asthma

BACKGROUND

Asthma may increase the risk of comorbid depressive disorders in children. Children suffering from asthma or depression are more often overweight. We examined whether depression was more likely in children with atopic and nonatopic asthma, independent of abdominal adiposity.

METHODS

A cross-sectional analysis was performed on data collected in the Study of Asthma, Genes, and Environment in Canada. Children aged 11 to 14 years were assessed by a pediatric allergist to confirm asthma, allergic rhinitis, and atopic dermatitis diagnosis. Atopic asthma was defined based on skin prick testing and allergic asthma based on the presence of allergic rhinitis or atopic dermatitis in addition to asthma. Depressive symptoms were assessed using the Children's Depression Inventory-Short Form. Data were analyzed using logistic regression modeling to determine likelihood of depression in children with asthma, stratified by gender and adjusting for ethnicity, waist circumference (WC), and atopy.

RESULTS

Four hundred thirty-one children aged 11 to 14 years (136 with asthma and 295 without asthma) were studied. After adjusting for the covariates, girls who had nonatopic or nonallergic asthma were three times more likely to have comorbid depressive symptoms compared with healthy girls (OR, 2.84; 95% CI, 1.00-8.10; OR, 3.47; 95% CI, 1.30-9.25, respectively). For each 10-cm increase in WC of girls, our model showed a 39% to 56% increase in the chance of depression. In boys, neither asthma nor WC showed an association with depression.

CONCLUSIONS

We recommend all health practitioners who see girls with asthma or girls who are overweight watch for depressive symptoms and treat comorbid depression seriously.

Pathophysiology of food allergy

In this article we review the pathophysiology of food allergy, which affects 4% of US children and 2% of adults, and is increasing in prevalence. Most food allergens share certain specific physicochemical characteristics that allow them to resist digestion, thus enhancing allergenicity. During allergic sensitization, these allergens are encountered by specialized dendritic cell populations in the gut, which leads to T-cell priming and the production of allergen-specific IgE production by B cells. Tissue-resident mast cells then bind IgE, and allergic reactions are elicited when mast cells are reexposed to allergen. Adjacent IgE molecules bound to the surface of the mast cell become cross-linked, causing mast cell degranulation and release of powerful vasoactive compounds that cause allergic symptoms.

Mechanisms of immune tolerance relevant to food allergy

The intestine has an unenviable task: to identify and respond to a constant barrage of environmental stimuli that can be both dangerous and beneficial. The proper execution of this task is central to the homeostasis of the host, and as a result, the gastrointestinal tract contains more lymphocytes than any other tissue compartment in the body, as well as unique antigen-presenting cells with specialized functions. When antigen is initially encountered through the gut, this system generates a robust T cell-mediated hyporesponsiveness called oral tolerance. Although seminal observations of oral tolerance were made a century ago, the relevant mechanisms are only beginning to be unraveled with the use of modern investigational techniques. Food allergy is among the clinical disorders that occur from a failure of this system, and therapies that seek to re-establish tolerance are currently under investigation.

Bullying among pediatric patients with food allergy

BACKGROUND

There are reports of children and teens with food allergy being harassed because of their food allergy, yet no study to date has attempted to characterize these occurrences.

OBJECTIVES

To determine the presence and characteristics of bullying, teasing, or harassment of food-allergic patients owing to their food allergies.

METHODS

Questionnaires were completed by food-allergic teens and adults and by parents of food-allergic children.

RESULTS

A total of 353 surveys were completed. Because most food-allergic individuals were children, most surveys were completed by parents of food-allergic individuals. The ages of the food-allergic individuals were younger than 4 years (25.9%), 4 to 11 years (55.0%), 12 to 18 years (12.5%), 19 to 25 years (2.6%), and older than 25 years (4.0%). Including all age groups, 24% of respondents reported that the food-allergic individual had been bullied, teased, or harassed because of food allergy. Of those who were bullied, teased, or harassed, 86% reported multiple episodes. Eighty-two percent of episodes occurred at school, and 80% were perpetrated mainly by classmates. Twenty-one percent of those who were bullied, teased, or harassed reported the perpetrators to be teachers or school staff. Overall, 79% of those bullied, teased, or harassed attributed this solely to food allergy. Of those bullied, 57% described physical events, such as being touched by an allergen and having an allergen thrown or waved at them, and several reported intentional contamination of their food with allergen.

CONCLUSIONS

Bullying, teasing, and harassment of children with food allergy seems to be common, frequent, and repetitive. These actions pose emotional and physical risks that should be addressed in food allergy management.

Oral food desensitization

The immunologic interactions in the gastrointestinal tract are extensive and complex. In most cases, the end result of this activity is one of tolerance, which refers to the inhibition of an immune response. However, in a minority of cases, food allergy develops, and this seems to be increasing in prevalence. We continue to learn about the mechanisms involved in these processes and the factors that may promote tolerance as opposed to allergy. At this point, management of food allergy consists of allergen avoidance and readiness to manage an accidental exposure reaction, but using current knowledge of gastrointestinal immunity, researchers are investigating immunomodulatory approaches that will provide "active" therapy for food allergy and induce tolerance. Oral immunotherapy is one important therapy being studied, and in this article, we review recent results from studies of this potential treatment for food allergy.

A developmental, community, and psychosocial approach to food allergies in children

Recent estimates show that food allergies affect a substantial proportion of children in the United States and appear to have increased in prevalence. At present, management of food allergies consists of strict avoidance of the responsible allergen and an appropriate response should a reaction occur. Creating safe environments for the growing number of children with food allergies requires a partnership between affected families and members of the caregiving and educational communities. This article reviews issues affecting children with food allergies at different stages of psychosocial development and discusses strategies that can be implemented to promote food safety within child care and school environments as well as in the community. It also presents an overview of policy developments at the state and national level that have implications for children with food allergies.