Advancing Food Allergy Through Epidemiology: Understanding and Addressing Disparities in Food Allergy Management and Outcomes

Food Insecurity Screening in the Allergy/Immunology Clinic: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee

Food insecurity (FI) is defined by the US Department of Agriculture as reduced quality, variety, or desirability of a diet or reduced or disrupted intake of food. There is concern that children with food allergy (FA) may be more likely to be food insecure. The purpose of this project was to investigate the prevalence of FI in the pediatric allergy/immunology population and determine the impact of FA status, race and ethnicity, and geographic food access. An additional goal was to develop a workflow for FI screening in the allergy/immunology clinic setting. Parents of patients were given the validated 2-question Hunger Vital Sign questionnaire in English or Spanish. Those with physician-diagnosed FA were asked a third question about access to allergen-free foods. Families who screened positive for FI received a list of local resources and access to social work assistance. The response rate was 89.1%, with 179 completed surveys. Twenty-three percent of patients screened positive for FI. There was a significant association between race and ethnicity, age, and FI status. FA status and distance from the nearest grocery store were not significantly associated with FI. This study adds to the mounting evidence highlighting the burden of FI in the allergy/immunology population and serves as a call to action for practicing allergists. Efficient FI screening can be accomplished using widely available validated tools. Continued efforts will enable the development of targeted resources to meet this pressing need, with tailored solutions for those on specialized diets.

Omalizumab reduces anaphylactic reactions and allows food introduction in food-allergic in children with severe asthma: An observational study

BACKGROUND

In Europe, Omalizumab (anti-IgE) is indicated for the treatment of moderate to severe asthma, but not for IgE-mediated food allergy (FA).

OBJECTIVE

We assessed the impact of Omalizumab on efficacy, safety, and quality of life (FA-QoL) in patients with moderate to severe asthma and who have a history of anaphylaxis to peanut, tree nuts, fish, egg, milk, and/or wheat.

METHODS

Food-allergic children (6-18 years) with moderate to severe asthma underwent oral food challenges (OFCs) to establish the threshold of reaction to the culprit food(s) at baseline (T0) and at 4-month intervals (T1, T2, and T3) during their first year of treatment with Omalizumab. We recorded the number and severity of food-allergic reactions, Asthma Control Test (ACT) scores, FA-QoL, and total IgE levels.

RESULTS

In 65 patients allergic to 107 foods, the No Observed Adverse Events Level (NOAEL) at T1 increased: 243- and 488-fold for fresh and baked milk, respectively; 172- and 134-fold for raw and baked egg; 245-fold for hazelnut; 55-fold for peanut; 31-fold for wheat; and 10-fold for fish. Full tolerance was achieved in 66.4% of OFCs at T1, 58.3% at T2, and 75% at T3. Ninety-five foods were liberalized in the diet of 55 patients; the remaining 12 were introduced by 10 patients at least in traces. Throughout the study, 40 out of 65 were able to get a free diet. ACT increased from 17 (Q1-Q3: 15-17) to 23.6 (Q1-Q3: 23-25). The FA-QoL score in children ≤12 years decreased from 4.63 ± 0.74 to 2.02 ± 1.13, and in adolescents from 4.68 ± 0.92 to 1.90 ± 1.50.

CONCLUSIONS

During Omalizumab therapy, a safe reintroduction of allergenic foods is feasible.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT06316414.

Social Determinants and Quality of Life in Food Allergy Management and Treatment

Food allergies (FA) significantly affect the quality of life (QOL) and health-related QOL of patients and families managing this chronic condition. Social determinants of health (SDOH) are pivotal nonmedical factors that influence health outcomes and exacerbate disparities in FA diagnosis, treatment, and management. The five domains of SDOH (economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context) shape the lived experiences of individuals with FA. Challenges such as food insecurity, limited access to specialty care, and the high cost of allergen-free foods disproportionately burden under-resourced and marginalized populations, leading to gaps in care and adverse outcomes. This report explores the interplay between SDOH and FA management, focusing on the economic, emotional, and social barriers to optimal care. Furthermore, it highlights the importance of understanding domain-specific QOL, emphasizing tailored interventions to address inequities. Future research must prioritize inclusive representation in clinical trials, innovative strategies to overcome economic and systemic barriers, and tools to measure the unique QOL impacts of FA across diverse populations. Addressing these challenges is critical to promoting health equity and improving outcomes for all individuals affected by FA.

Depletion of eosinophils during sensitization but not challenge phase in mice blocks the development of food allergy early in life

Food allergy can be life threatening and often develops early in life, especially in infants and children with atopic dermatitis. Food allergy is induced in neonatal mice with skin barrier mutations (Flaky Tail, FT+/- mice with filaggrin and mattrin gene mutations) by epicutaneous sensitization with co-exposures to the food allergen peanut extract (PNE), the environmental allergen Alternaria alternata (Alt), and detergent (4% SDS); oral PNE-challenge induces anaphylaxis. Sensitization in these neonates also induces eosinophil infiltration into the skin and elevates skin expression of eotaxins (CCL11 and CCL24). However, roles for eosinophils in food allergy are not known. In this study, the iPhil+/- FT+/- pups, which have an inducible eosinophil-deficiency upon injection of diphtheria toxin (DTX), were sensitized and then received PNE by gavage to assess anaphylaxis. DTX depletion of eosinophils, during sensitization and oral PNE-challenge, blocked the recruitment and activation of mast cells, blocked the Alt+PNE-induced increase in plasma IL-33 and OSM, attenuated serum PNE-specific IgE/IgG1/IgG2b, and blocked oral-PNE-induced anaphylaxis. Anti-IL-5 depletion of eosinophils during sensitization/challenge also blocked anaphylaxis. When eosinophils were depleted during allergen-skin-sensitization and restored before oral PNE-challenge, anaphylaxis was blocked. In contrast, when eosinophils were present during allergen-skin-sensitization but then depleted during oral PNE-challenge, anaphylaxis was not blocked. Together, these data indicate that although eosinophils are not necessary during oral food allergen-induced anaphylaxis, eosinophils have a critical role during the development of food allergy early in life by regulating the sensitization-induced increase in mast cell numbers and food allergen-specific IgE.

Challenges in designing interventions for food insecure families with food allergy in a Californian latinx cohort

Food allergy poses substantial social, economic, and quality of life burdens which are even heavier for families that are struggling with food insecurity. In the United States (US), food insecurity disproportionately affects vulnerable and historically marginalized communities, such as Latino/a/x and Black households. Targeting these disparities via our recent Food Equality Initiative (FEI) research intervention was challenging due to the barriers faced by the target underserved populations, which included poor digital literacy, language barriers, and limited access to necessary resources. These barriers hindered our efforts to promote access to nutritious and safe food options for food-insecure families, potentially further exacerbating health disparities. Here we discuss common challenges and opportunities associated with conducting research interventions in underserved communities in the US-leveraging our experiences designing and implementing an intervention to improve food allergy management through supplemental nutrition assistance in a predominantly Spanish-speaking, lower-income neighborhood in Northern California. We also provide recommendations for other researchers regarding how to tailor research strategies to address these challenges, and in so doing reduce health disparities and promote positive health outcomes for vulnerable and historically marginalized communities.

Differences in familiarity with oral immunotherapy among caregivers of White and Black children with food allergy

BACKGROUND

Potential racial and ethnic disparities related to oral immunotherapy (OIT) have not been fully described among children with food allergy (FA).

OBJECTIVE

To characterize the differences in attitudes toward, familiarity with, and utilization of OIT among non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic or Latino (H/L) caregivers of children with FA.

METHODS

Surveys were administered to the caregivers of children enrolled in Food Allergy Outcomes Related to White and African American Racial Differences, a prospective, multisite cohort of children with FA. The distribution of responses by caregiver-reported race and ethnicity was described using an analysis of variance for continuous outcomes and χ2 tests for categorical outcomes. A logistic regression model was used to determine associations between familiarity with OIT as a treatment option and various other covariates.

RESULTS

The NHB and H/L respondents were more frequently not familiar with OIT compared with NHW responders (54.3% and 62.5% vs 9.2%, P < .001). This finding remained true, even after adjusting for household income (odds ratio: 0.1, 95% CI: 0.1-0.4 for NHB participants and odds ratio: 0.1, 95% CI: 0.0-0.3 for H/L participants). NHB and H/L participants more frequently reported that they had never heard of OIT before the survey compared with NHW participants (76.7% and 50.0% vs 26.7%, P < .001). None of the NHB and H/L respondents initiated OIT compared with 14.8% of NHW participants (P < .001).

CONCLUSION

In the Food Allergy Outcomes Related to White and African American Racial Differences cohort, familiarity with OIT was lower among caregivers of minoritized racial and ethnic groups, even after adjusting for household income.

Timing of Food Introduction and Allergy Prevention: An Update

Recommendations about allergy prevention through diet are rapidly changing. In just the past several years, multiple organizations have provided updated guidance and recommendations about infant feeding based on recent studies and meta-analyses. In addition to the increased number of studies supporting the benefit of early introduction of allergenic foods, in particular peanut and egg, recent studies demonstrate that infant and maternal diet diversity may also reduce risk of food allergy and atopy. Skin emollients have not been found to be helpful in prevention of food allergy, and more evidence is needed to determine if emollients play a role in prevention of atopic dermatitis.

Racial and Ethnic Representation in Food Allergen Immunotherapy Trial Participants: A Systematic Review

Importance

The lack of inclusion of diverse population samples in food allergy immunotherapy clinical trials not only leads to decreased applicability to the general population in terms of results and treatments but can also be seen as a broader social injustice contributing to inequity within the health care system.

Objectives

To investigate the racial and ethnic distribution of participants included in food allergy immunotherapy clinical trials, and determine whether the racial and ethnic representation in trials accurately reflects the patients who experience food allergy.

Evidence Review

Data were collected from articles found on PubMed and ClinicalTrials.gov using key terms of food hypersensitivity, food allergy, and immunotherapy, while also incorporating specific criteria such as clinical trials conducted within the last 5 years with children aged from birth to 18 years old. Articles were selected based on their relevance to the research question. Main outcomes were totals and percentages of trial participants by race and ethnicity, stratified by pediatric trials, site of study, and National Institutes of Health funding.

Findings

Thirty-five articles were initially identified, of which 34 were classified as human clinical trials. Of these trials, 26 met criteria of an original randomized clinical trial and included racial and ethnic demographics for analysis in the study. Among trials included, the majority of the 3689 participants identified as White (2640 participants [72.0%]), followed by Black or African American (293 participants [8.0%]), Asian (239 participants [6.0%]), multiple races or other (210 participants [6.0%]), Hispanic or Latino (96 participants [3.0%]), American Indian (3 participants [<1.0%]), and Native American or Pacific Islander (3 participants [<1.0%]). We observed differences in racial and ethnic inclusion by study site (US vs external to US) and funding support (National Institutes of Health vs industry or other non-National Institutes of Health sources).

Conclusions and Relevance

In this systematic review of racial and ethnic diversity in food allergy immunotherapy trials, there was a lack of diversity relative to the overall food allergy burden among Black and Hispanic patients, indicating important gaps in the conduct of pediatric clinical trials, especially for treatments that are meant for use in broad populations where significant race- and ethnicity-related disparities exist. Working to correct this disparity will not only increase the usefulness of future clinical trial data but can further assist in alleviating public health inequities.

Racial and Socioeconomic Disparities Exist in Patients Pursuing Peanut Oral Immunotherapy

BACKGROUND

Oral immunotherapy (OIT) is a promising treatment for food allergy. Prior studies demonstrate significant differences among food-allergic individuals across race, ethnicity, and socioeconomic groups. Disparities in OIT have not been evaluated.

OBJECTIVE

We assessed disparities in the use of OIT in patients with peanut allergy based on race, ethnicity, and socioeconomic status at a single academic medical center.

METHODS

We identified 1028 peanut-allergic patients younger than 18 years receiving care in the University of Michigan food allergy clinics. Of these, 148 patients who underwent peanut OIT (treatment group) were compared with the 880 patients who avoided peanut (control group). Pertinent demographic and socioeconomic characteristics were compared.

RESULTS

There were no differences in gender or ethnicity between the OIT and control groups. However, Black patients comprised 18% of the control group but only 4.1% of the OIT treatment group (P < .0001). The proportion of patients with private insurance was significantly higher in the treatment group compared with the control group (93.2% vs 82.2%, P = .0004). Finally, the neighborhood affluence index, a census-based measure of the relative socioeconomic prosperity of a neighborhood, was significantly higher in the OIT group than the control group (0.51 ± 0.18 vs 0.47 ± 0.19, P = .015), whereas the neighborhood disadvantage index, a census-based measure of the relative socioeconomic disadvantage of a neighborhood, was significantly lower (0.082 ± 0.062 vs 0.10 ± 0.093, P = .020).

CONCLUSIONS

Significant racial and economic disparities exist at our institution between peanut-allergic individuals who receive OIT and those who do not. Efforts to understand the basis for these disparities are important to ensure that patients have equitable access to OIT.

Immunotherapy and biologics in the management of IgE-mediated food allergy: Systematic review and meta-analyses of efficacy and safety

Food allergy (FA) is a potentially life-threatening chronic condition that is becoming an increasing public health problem worldwide. This systematic review (SR) was carried out to inform the development of clinical recommendations on the treatment of IgE-mediated FA with biologics and/or IT for the update of the EAACI guidelines. A SR of randomized-controlled trials or quasi-controlled trials was carried out. Studies were identified via comprehensive search strategies in Medline, Embase, and Cochrane Library, up to April 2022.

POPULATION

Human adults, children, and adolescents with IgE-mediated FA.

INTERVENTION

IT and/or biologics.

COMPARATOR

Placebo or standard-of-care (allergen avoidance).

OUTCOME

Efficacy (desensitization, sustained unresponsiveness (SU), remission), quality of life, and safety (systemic and local adverse reactions (AR)). The Cochrane RoB tool was used to assess the risk of bias. It was reported according to PRISMA and registered in PROSPERO CRD4202229828. After screening, 121 studies were included (111 for IT and 10 for biologics). Most studies had a high risk of bias and showed high heterogeneity in design and results. Metanalysis showed a positive effect of biologics and IT in terms of relative risk (RR) for achieving tolerance to the culprit food compared to avoidance or placebo. Omalizumab for any FA showed a RR of 2.17 [95% confidence interval: 1.22, 3.85]. For peanut allergy, oral IT (OIT) had a RR of 11.94 [1.76, 80.84] versus avoidance or placebo, sublingual IT (SLIT) had a RR of 3.00 [1.04, 8.66], and epicutaneous IT (EPIT) of 2.16 [1.56, 3.00]. OIT had a RR of 5.88 [2.27, 15.18] for cow's milk allergy, and of 3.43 [2.24, 5.27] for egg allergy. There was insufficient data on SLIT or EPIT for the treatment of egg and milk allergies. Most ARs reported were mild. For OIT the most common AR involved the gastrointestinal system and for EPIT, AR's most commonly affected the skin. There was limited data on severe or life-threatening ARs. There was limited evidence for long term efficacy and quality of life. In conclusion, biologics and IT, alone or in combination, are effective in achieving desensitization while on active treatment but more evidence is needed on long-term tolerance as current evidence is not of high quality. Adverse events while on therapy are generally mild to moderate but a long-term comprehensive safety profile is missing. There is a critical need to optimize and standardize desensitization protocols and outcome measures to facilitate our understanding of the efficacy and safety as well as to allow for comparison between interventions.

Sociodemographic inequities in food allergy: Insights on food allergy from birth cohorts

A large and growing corpus of epidemiologic studies suggests that the population-level burden of pediatric FA is not equitably distributed across major sociodemographic groups, including race, ethnicity, household income, parental educational attainment, and sex. As is the case for more extensively studied allergic disease states such as asthma and atopic dermatitis epidemiologic data suggest that FA may be more prevalent among certain populations experiencing lower socioeconomic status (SES), particularly those with specific racial and ethnic minority backgrounds living in highly urbanized regions. Emerging data also indicate that these patients may also experience more severe FA-related physical health, psychosocial, and economic outcomes relating to chronic disease management. However, many studies that have identified sociodemographic inequities in FA burden are limited by cross-sectional designs that are subject to numerous biases. Compared with cross-sectional study designs or cohorts established later in life, birth cohorts offer advantages relative to other study designs when investigators seek to understand causal relationships between exposures occurring during the prenatal or postnatal period and the atopic disease status of individuals later in life. Numerous birth cohorts have been established across recent decades, which include evaluation of food allergy-related outcomes, and a subset of these also have measured sociodemographic variables that, together, have the potential to shed light on the existence and possible etiology of sociodemographic inequities in food allergy. This manuscript reports the findings of a comprehensive survey of the current state of this birth cohort literature and draws insights into what is currently known, and what further information can potentially be gleaned from thoughtful examination and further follow-up of ongoing birth cohorts across the globe.

Rural Health Disparities in Allergy, Asthma, and Immunologic Diseases: The Current State and Future Direction for Clinical Care and Research

Rural health disparities are well documented and continue to jeopardize the long-term health and wellness for the millions of individuals who live in rural America. The disparities observed between urban and rural residents encompass numerous morbidity and mortality measures for several chronic diseases and have been referred to as the "rural mortality penalty." Although the unmet health needs of rural communities are widely acknowledged, little is known about rural health disparities in allergies, asthma, and immunologic diseases. Furthermore, the intersection between rural health disparities and social determinants of health has not been fully explored. To achieve a more complete understanding of the factors that perpetuate rural health disparities, greater research efforts followed by improved practice and policy are needed that account for the complex social context within rural communities rather than a general comparison between urban and rural environments or focusing on biomedical factors. Moreover, research efforts must prioritize community inclusion throughout rural areas through meaningful engagement of stakeholders in both clinical care and research. In this review, we examine the scope of health disparities in the rural United States and the impact of social determinants of health. We then detail the current state of rural health disparities in the field of allergy, asthma, and immunology. To close, we offer future considerations to address knowledge gaps and unmet needs for both clinical care and research in addressing rural health disparities.

Commensal bacteria signal through TLR5 and AhR to improve barrier integrity and prevent allergic responses to food

The increasing prevalence of food allergies has been linked to reduced commensal microbial diversity. In this article, we describe two features of allergy-protective Clostridia that contribute to their beneficial effects. Some Clostridial taxa bear flagella (a ligand for TLR5) and produce indole (a ligand for the aryl hydrocarbon receptor [AhR]). Lysates and flagella from a Clostridia consortium induced interleukin-22 (IL-22) secretion from ileal explants. IL-22 production is abrogated in explants from mice in which TLR5 or MyD88 signaling is deficient either globally or conditionally in CD11c+ antigen-presenting cells. AhR signaling in RORγt+ cells is necessary for the induction of IL-22. Mice deficient in AhR in RORγt+ cells exhibit increased intestinal permeability and are more susceptible to an anaphylactic response to food. Our findings implicate TLR5 and AhR signaling in a molecular mechanism by which commensal Clostridia protect against allergic responses to food.

Promises and Remaining Challenges for Further Integration of Basophil Activation Test in Allergy-Related Research and Clinical Practice

More than 20 years after having been initially proposed, the relevance and usefulness of basophil activation test (BAT) for the field of allergy research and testing were demonstrated on many occasions. Leveraging the fully open format of a flexible, whole blood-based functional assay, BAT has been shown to be equally important for fundamental research, clinical research, and diagnosis. Regardless of whether the focus of a study is on the characterization of the allergenic moiety, on the patient side, or on the study of the fundamental processes involved in the allergic disease or its treatment, BAT enables the gathering of very important insights. In spite of this, its full capabilities have yet to be leveraged. Various bottlenecks, including but not limited to assay logistics, robustness, flow cytometry access, and/or expertise, have indeed been limiting its development beyond experts and long-term users. Now, various initiatives, aiming at resolving these bottlenecks, have been launched. If successful, a broader use of BAT could then be contemplated. In such a situation, its more thorough integration in clinical practice has the potential to significantly change the allergic patient's journey.

Historical and social science perspectives on food allergy

This article provides an overview of the insights social scientists, historians and other health humanities scholars have made to our understanding of food allergies. It shows how humanities and social science scholars have tended to address three pivotal issues related to food allergies: first, they have addressed the epidemiology of food allergies, including the apparent rise in the rate of food allergies and the emergence of theories that purport to explain why food allergies may be increasing. These include theories related to changes in food consumption and the hygiene hypothesis. Second, humanities and social science scholars have researched how risks related to food allergies have been constructed, understood, experienced and mitigated. Third, humanities and social science scholars have investigated the experiences of food allergy sufferers and those who care for them, providing valuable qualitative insights that can inform how we respond to food allergy and our understanding of the aetiology of food allergy. The article concludes with three recommendations. First, there should be a more interdisciplinary approach to food allergy research that involves social scientists and health humanities scholars. Second, humanities and social sciences scholars should be more willing to unpack and scrutinise the theories put forward to explain the aetiology of food allergies, rather than accepting them at face value. And finally, humanities and social sciences scholars can play a major role in ensuring that the experiences of patients and their carers are articulated and fed into debates about food allergy, including its causes and how to respond to it.

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions

Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country's response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Viewing Pediatric Food Oral Immunotherapy Through an Ethical Lens-A Narrative Systematic Review

BACKGROUND

Food allergy remains a common problem and a lifelong condition for many children. In recent years, food allergy management has increasingly involved conversations about food oral immunotherapy (OIT). Although ethical considerations of autonomy, beneficence, nonmaleficence, and justice implicitly inform these conversations, applying these principles can be complex, particularly in young children. Families of young children assume a role of surrogate decision-maker and must balance immediate risks with the hope of longer-term benefits.

OBJECTIVE

To explore implementation of OIT in children through an ethical lens.

METHODS

To evaluate OIT through an ethical lens, we conducted a literature search to explore currently published frameworks in this area.

RESULTS

Evaluation of the harm principle, the basic interest principle, and the best interest principle of parental decision-making can be informative. Shared decision-making continues to be central to the process of engaging with patient-family units to individualize the best care, at the right time, and minimize decisional discord. Although OIT is well-positioned to promote health and well-being, challenges to equity, sustainability, and organizational support must be considered to improve access for appropriate patients.

CONCLUSIONS

Whereas approaches to food OIT may be tailored to the individual context of each patient-family unit, ethical principles must guide decisions to initiate and continue therapy. Traditional ethical principles of autonomy, beneficence, nonmaleficence, and justice remain cornerstones when considering the ethical context of OIT.

Relationship between eliciting doses and the severity of allergic reactions to food

PURPOSE OF REVIEW

Food allergies with low thresholds are associated with frequent accidental allergic reactions. Severe reactions attributable to accidental ingestion often result in a poor quality of life. Nevertheless, no evidence of a relationship between a low threshold dose and the severity of symptoms exists. Therefore, we evaluated recent data regarding the threshold of food allergies based on the oral food challenge (OFC). We also proposed a stepwise OFC method to identify threshold and consumable doses.

RECENT FINDINGS

A higher specific IgE level and a history of food-induced anaphylaxis were related to low threshold doses and severe reactions during the OFC. In addition, a low threshold dose was not directly correlated with severe reactions. Performing a stepwise OFC may help safely clarify consumable doses and prevent the complete avoidance of allergy-causing foods.

SUMMARY

Severe food allergies with high specific IgE levels are associated with lower thresholds and more severe reactions. However, the threshold is not directly related to the severity of food-induced allergic symptoms. Identifying a well tolerated consumable dose using a stepwise OFC may help manage food allergies.

Differences in Self-Reported Food Allergy and Food-Associated Anaphylaxis by Race and Ethnicity Among SAPPHIRE Cohort Participants

BACKGROUND

Although food allergies are considered common, relatively little is known about disparities in food allergy by race in the United States.

OBJECTIVE

To evaluate differences in reported food allergy and food-associated anaphylaxis among individuals enrolled in a longitudinal cohort study from metropolitan Detroit, Michigan.

METHODS

Participants in the Study of Asthma Phenotypes and Pharmacogenomic Interactions by Race-Ethnicity (SAPPHIRE) were asked about food allergies, including the inciting food and associated symptoms. Individuals were considered to have food-associated anaphylaxis if symptoms coincided with established clinical criteria. Logistic regression was used to assess whether race difference persisted after adjusting for and stratifying by potential confounders. African genetic ancestry was individually estimated among African American SAPPHIRE participants to assess whether ancestry was associated with food allergy.

RESULTS

Within the SAPPHIRE cohort, African American participants were significantly more likely to report food allergy (26.1% vs 17%; P = 3.47 × 10-18) and have food-associated anaphylactic symptoms (12.7% vs 7%; P = 4.65 × 10-14) when compared with European American participants. Allergy to seafood accounted for the largest difference (13.1% vs 4.6%; P = 1.38 × 10-31). Differences in food allergy by race persisted after adjusting for potential confounders including asthma status. Among African American participants, the proportion of African ancestry was not associated with any outcome evaluated.

CONCLUSION

Compared with European Americans, African Americans appear to be at higher risk for developing food allergy and food-associated anaphylaxis, particularly with regard to seafood allergy. The lack of association with genetic ancestry suggests that socioenvironmental determinants may play a role in these disparities.

Validated anxiety assessments among pediatric patients with peanut allergy on oral immunotherapy

BACKGROUND

Although efficacy, safety, and quality of life measures associated with peanut oral immunotherapy (OIT) have been studied, the relationship between peanut OIT and clinical anxiety has not yet been evaluated. The latter is important to help providers and families have an improved shared medical decision discussion around the benefits of initiating OIT.

OBJECTIVE

To investigate the relationship between undergoing OIT and anxiety in patients with peanut allergy.

METHODS

In this prospective cross-sectional cohort study, using validated and age-appropriate anxiety scales administered with electronic survey questionnaires, we used generalized linear regressions to compare anxiety between patients undergoing OIT and similar patients with peanut allergy but not on OIT (controls).

RESULTS

In the younger cohort (<7 years, n = 80), there was generally a low prevalence of diagnosable anxiety across patients on OIT and controls. In the older cohort (>7 years, n = 125), there was a higher prevalence of anxiety but no clinically meaningful difference between anxiety scores of patients on OIT and controls. In the older cohort, patients with asthma were more likely to have higher mean anxiety scores (P = .04), as were female patients compared with male patients (P = .004). A subanalysis of separation anxiety scores in the older cohort revealed that younger age (7-12 years vs >12 years, P < .001), non-White race (P = .04), and eczema (P = .02) were found to be meaningful predictors of higher scores. A subanalysis of social anxiety on the older cohort pointed toward non-White race as a meaningful predictor of higher scores (P < .02).

CONCLUSION

The clinical implications of these findings suggest that allergists should particularly consider screening children with food allergy for anxiety and anxiety subtypes among patients who are non-White, female, or have asthma.

New considerations of health disparities within allergy and immunology

The pandemic, political upheavals, and social justice efforts in our society have resulted in attention to persistent health disparities and the urgent need to address them. Using a scoping review, we describe published updates to address disparities and targets for interventions to improve gaps in care within allergy and immunology. These disparities-related studies provide a broad view of our current understanding of how social determinants of health threaten patient outcomes and our ability to advance health equity efforts in our field. We outline next steps to improve access to care and advance health equity for patients with allergic/immunologic diseases through actions taken at the individual, community, and policy levels, which could be applied outside of our field. Key among these are efforts to increase the diversity among our trainees, providers, and scientific teams and enhancing efforts to participate in advocacy work and public health interventions. Addressing health disparities requires advancing our understanding of the interplay between social and structural barriers to care and enacting the needed interventions in various key areas to effect change.

Psychosocial functioning in pediatric food allergies: A scoping review

The psychosocial burden of food allergy (FA) can significantly affect the lives of pediatric patients and their families. A comprehensive understanding of the state of the literature on psychosocial functioning is imperative to identify gaps that may affect clinical care and future research. This review characterizes the current literature on psychosocial functioning in pediatric patients with FA and their caregivers, siblings, and families. A literature search of 5 databases (PubMed, Ovid MEDLINE, PsycINFO, Web of Science, and Embase) was conducted to identify original research articles and abstracts on psychosocial functioning of patients with FA who were aged 0 to 18 years and their caregivers, siblings, and families. A total of 257 studies met the inclusion criteria. The majority of studies examined child or caregiver psychosocial functioning, with child and caregiver quality of life examined most frequently. Most studies utilized quantitative and cross-sectional methods and inconsistently reported participant race and ethnicity. Existing research on psychosocial functioning in pediatric FA may not be generalizable to patients of color and families and siblings. Future research should diversify recruited samples regarding race, ethnicity, and country of origin; examine psychosocial functioning longitudinally; examine constructs beyond quality of life; and adopt a biopsychosocial approach by considering the interplay among psychosocial functioning, disease burden, and social contexts.

Disparities in the Diagnosis and Management of Anaphylaxis

PURPOSE OF REVIEW

The goal of this review is to characterize health disparities impacting the recognition and treatment of anaphylaxis.

RECENT FINDINGS

Previous research has identified major health disparities related to atopic conditions including asthma, atopic dermatitis, and food allergies (FA); however, disparities related to anaphylaxis have yet to be examined in depth. We found widespread health disparities in the incidence and severity of anaphylaxis, as well as in the management of allergies (particularly food allergies) that place individuals at risk of anaphylaxis. Sociodemographic factors are associated with numerous negative health outcomes related to anaphylaxis. We highlight several key steps that must be taken to address these disparities.

Impact of Social Determinants of Health in Spine Surgery

PURPOSE OF REVIEW

Social determinants of health (SDH) are factors that affect patient health outcomes outside the hospital. SDH are "conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." Current literature has shown SDH affecting patient reported outcomes in various specialties; however, there is a dearth in research relating spine surgery with SDH. The aim of this review article is to identify connections between SDH and post-operative outcomes in spine surgery. These are important, yet understudied predictors that can impact health outcomes and affect health equity.

RECENT FINDINGS

Few studies have shown associations between SDH pillars (environment, race, healthcare, economic, and education) and spine surgery outcomes. The most notable relationships demonstrate increased disability, return to work time, and pain with lower income, education, environmental locations, healthcare status and/or provider. Despite these findings, there remains a significant lack of understanding between SDH and spine surgery. Our manuscript reviews the available literature comparing SDH with various spine conditions and surgeries. We organized our findings into the following narrative themes: 1) education, 2) geography, 3) race, 4) healthcare access, and 5) economics.

Food allergy in the World Health Organization's International Classification of Diseases (ICD)-11

There are increasing global data regarding the prevalence of food allergy and food-induced anaphylaxis. However, knowledge in morbidity and mortality epidemiological data is still not optimal, and international comparable standards remain poorly accessed. This information could in turn support better clinical practice and possibly prevent future severe reactions and avoidable fatalities. The International Classification of Diseases (ICD) is the standard diagnostic tool used for epidemiology, health management, and clinical purposes supported by the World Health Organization (WHO). It is also used to determine health care payment and reimbursement of providers and health care services in hospitals. Thanks to the academic and technical efforts under the ALLERGY in ICD-11 initiative the pioneer "Allergy and hypersensitivity conditions" section has been built under the "Disorders of the Immune System" chapter of the ICD-11. The "Food hypersensitivity" (FH) subsection is classified under the "Complex allergic or hypersensitivity conditions" section and "Food-induced anaphylaxis" is under the "Anaphylaxis" section. In order to inform the development of strategies to reduce preventable FHs/food allergies, the burden of disease in different healthcare settings and patient populations and their common etiologies need to be understood. Besides, greater specificity regarding clinical conditions and services delivered will provide payers, policy makers, and providers with better information to make major refinements to countries payment and reimbursement systems, including the design and implementation of pay-for-performance program.The new classification addressed to FHs will enable the collection of more accurate epidemiological data to support quality management of patients with FHs/food allergies, and better facilitate health care planning and decision-making and public health measures to prevent and reduce their morbidity and mortality. The improved logic and standardized definitions through the ICD-11 (and other WHO classifications) will also facilitate international comparisons of quality care and the sharing of best practice globally.

Early Introduction of Allergenic Foods and the Prevention of Food Allergy

The increasing prevalence of food allergies is a growing public health problem. For children considered high risk of developing food allergy (particularly due to the presence of other food allergies or severe eczema), the evidence for the early introduction of allergenic foods, and in particular peanut and egg, is robust. In such cases, the consensus is clear that not only should such foods not be delayed, but that they should be introduced at approximately 4 to 6 months of age in order to minimize the risk of food allergy development. The early introduction of allergenic foods appears to be an effective strategy for minimizing the public health burden of food allergy, though further studies on the generalizability of this approach in low-risk populations is needed.

The US population-level burden of cow's milk allergy

Background

Cow's milk is a food allergen of public health importance both in the United States and globally. Its natural history and epidemiology have been most studied among infants and young children, but the public health burden it places on adults and older pediatric populations remains unclear. This study comprehensively characterizes the US population-level burden of cow's milk allergy (CMA), including its prevalence, severity, health care utilization, psychosocial impact, natural history, and other associated factors-including ability to tolerate extensively heated milk products-within a large, nationally-representative survey sample of US households.

Methods

A cross-sectional survey was administered via web and telephone. Population level inference was based on data collected from participants recruited from National Opinion Research Center (NORC) at the University of Chicago's probability-based AmeriSpeak panel. Established dual-sample complex survey calibration methods were used to augment this sample with additional participants recruited through Survey Sampling International to increase the precision of the resulting estimates. In total, surveys were administered to a nationally representative sample of 51 819 US households from October 1, 2015, through September 31, 2016. Self-report responses from 40 453 adults and parent-proxy report for 38 408 children were analyzed.

Results

Analyzing survey responses from 78 851 individuals, an estimated 4.7% (95% CI, 4.4%-4.9%) of the US population reported current CMA, whereas 1.9% (95% CI, 1.8%-2.1%) met symptom-report criteria for convincing IgE-mediated allergy. An estimated 0.9% (95% CI, 0.8%-1.0%) had CMA that met convincing symptom-report criteria and was physician diagnosed. Female and White respondents were more likely to report outgrowing CMA relative to males and those reporting other races and ethnicities. Individuals with CMA who reported tolerance to baked milk products were less likely to report severe reaction histories (33.5% vs 42.7%; p = .03), a lifetime history of food allergy-related emergency department visits (43.4% vs. 55.8%; p = .005), and treating a milk-allergic reaction with epinephrine (10.6 vs. 18.9%; p = .003). These individuals also exhibited less psychosocial burden on the validated Food Allergy Independent Measure (FAIM) than their counterparts with CMA who were allergic to baked forms of milk.

Conclusion

These data indicate a discrepancy in reported rates of allergy to cow's milk among the US general population ranging from approximately 1 in 20 with reported CMA to fewer than 1 in 50 with physician-confirmed CMA. However, they suggest a substantial population-level burden of CMA, including substantial healthcare utilization, psychosocial burden and nutritional impacts-particularly among the approximately 30% of individuals with CMA who cannot tolerate baked forms of milk.

Oral immunotherapy for food allergy in children: is it worth it?

INTRODUCTION

Oral immunotherapy (OIT) is effective at inducing desensitization in food-allergic individuals, and is a valid therapeutic option for those allergic to peanut, cow's milk and egg. However, there is a high rate of dose-related adverse events, and at least one fatality to OIT has been reported.

AREAS COVERED

We provide an update on the broader framework of issues which will impact on the availability and uptake of OIT.

EXPERT OPINION

The need for standardized products remains controversial. A licensed product exists for peanut-OIT, but OIT can also be safely achieved using peanut-containing foods at much lower cost. For other allergens, OIT can only be done with non-pharma products - something which has been done safely for over 2 decades. There is a need to develop personalized protocols for OIT, particularly for the 20% of patients unable to tolerate standard OIT. Cost-effectiveness is dependent on improved quality of life, but evidence for this is currently lacking, and is a key evidence gap. OIT is likely to be cost-effective, particularly if noncommercial products are used. There may be a trade-off: in patients with lower reaction thresholds, a commercial product may be needed for initial updosing, until a level of desensitization is achieved when they can be switched to natural food products.

Establishment of an Epicutaneously Sensitized Murine Model of Shellfish Allergy and Evaluation of Skin Condition by Raman Microscopy

Background: Shellfish allergy is one of the most common food allergies. Recent studies have shown that sensitization to allergens via the skin is involved in the development of food allergies. In this study, a mouse model of shrimp allergy was generated by epicutaneous sensitization and used to identify skin conditions associated with susceptibility to sensitization. Methods: Four-week-old female BALB/c mice were sensitized by repeated application of 0.1 mg of tropomyosin to tape-stripped skin on days 0, 7, and 15, followed by a challenge on days 28 and 35. Results: Epicutaneously sensitized mice exhibited higher serum levels of tropomyosin-specific IgE on day 15 than control mice. After the oral challenge, model mice had higher anaphylaxis scores and lower rectal temperature. After three tape-strip treatments for sensitization, the skin was analyzed by Raman microscopy. The sensitized mice exhibited lower relative intensities of Raman bands at 399, 915, and 1073 cm−1 than control mice, which could be helpful noninvasive markers in screening for potential sensitization via the skin. Conclusions: An epicutaneous sensitization shellfish allergy model was generated. This model will be useful in studies to elucidate the pathogenesis of skin sensitization. Raman microscopy may also be valuable for capturing subtle skin changes leading to sensitization.

Maillard Reaction Induced Changes in Allergenicity of Food

Food allergy is increasing in prevalence, posing aheavier social and financial burden. At present, there is still no widely accepted treatment for it. Methods to reduce or eliminate the allergenicity of trigger foods are urgently needed. Technological processing contributes to producing some hypoallergenic foods. Among the processing methods, the Maillard reaction (MR) is popular because neither special chemical materials nor sophisticated equipment is needed. MR may affect the allergenicity of proteins by disrupting the conformational epitope, disclosing the hidden epitope, masking the linear epitope, and/or forming a new epitope. Changes in the allergenicity of foods after processing are affected by various factors, such as the characteristics of the allergen, the processing parameters, and the processing matrix, and they are therefore variable and difficult to predict. This paper reviews the effects of MR on the allergenicity of each allergen group from common allergenic foods.

Associations of Food Allergy-Related Dietary Knowledge, Attitudes, and Behaviors Among Caregivers of Black and White Children With Food Allergy

BACKGROUND

The increasing prevalence of pediatric food allergy (FA) in the United States has disproportionately affected non-Hispanic Black youth. However, racial and other socioeconomic disparities in FA management among caregivers of children with FA remain unclear.

OBJECTIVE

To determine associations between socioeconomic, clinical, and health care factors and FA-related knowledge, attitudes, and behaviors among caregivers of Black and White children with FA.

DESIGN

Cross-sectional survey analysis from the Food Allergy Outcomes Related to White and African American Racial Differences Study.

PARTICIPANTS/SETTINGS

Longitudinal cohort of caregivers of 385 Black and White children with FA ages birth to 12 years residing in Chicago, Illinois, Cincinnati, Ohio, and Washington, DC from 2017 to March 2021.

MAIN OUTCOME MEASURES

There were 3 primary outcomes of interest: (1) FA knowledge assessed by scores from the Knowledge Survey, (2) FA-related attitudes assessed by newly developed survey, and (3) food-related behaviors assessed by the FORWARD Diet and Purchasing Habit Surveys completed 6 months postenrollment.

ANALYSES

Multivariable linear and logistic regression.

RESULTS

The overall response rate to the 6-month postenrollment survey was 51.3% (385 of 751). White caregivers represented 69.4% of the participants. Black race was associated with a 1.5-point mean decrease in FA knowledge score (95% CI: -2.2 to -0.7) compared with White caregivers, and a graduate degree or bachelor's degree was associated with associated with a 1.7-point mean increase (95% CI: 0.8-2.7) and 1.1-point mean increase (95% CI: 0.2-2.0) in FA knowledge score, respectively, compared with caregivers who had less than a bachelor's degree. Multiple FAs and ever visited the emergency department for a food-related allergic reaction were also associated with higher levels of FA knowledge. Ever visited the emergency department for FA was also associated with higher odds of 2 measures of FA attitudes reflecting parental anxiety. Greater FA knowledge scores were consistently associated with lower odds of several FA-related food purchasing and eating behaviors assumed to have elevated risk of FA. Eating food prepared at school was the only FA behavior associated with race. Compared with White children, Black children were 2.5 times more likely to eat school-prepared foods (95% CI: 1.2-5.6).

CONCLUSIONS

Findings from this study identified socioeconomic, racial, and clinical factors associated with caregivers' FA-related knowledge, attitudes, and behaviors, but further research is warranted to better understand these relationships.

B cells and food allergy

PURPOSE OF REVIEW

B cells are known in food allergy pathogenesis for their production of IgE but their roles in the development of tolerance to foods are not well understood. Further understanding of B-cell biology in the context of food allergy is essential for the creation of effective prevention strategies and therapies.

RECENT FINDINGS

The majority of allergen-specific IgE in humans appears to arise from antigen-experienced B cells that have already undergone class switch recombination to other antibody isotypes, such as IgG1, and can also be produced by cells class switching to IgE locally in the gastrointestinal tract. Allergen-specific IgG4 can have protective effects in individuals and is associated with tolerance. Regulatory B cells, which can produce allergen-specific IgG4, are reduced in food-allergic individuals and may also be an important component of tolerance. Therapeutic approaches that block the generation and action of IgE and that enhance tolerizing immune responses are being evaluated for the treatment of food allergy.

SUMMARY

B cells play several roles in the development of food allergy versus tolerance. Their functions may translate into the care of food allergy as biomarkers or therapeutic targets and can be employed in other atopic diseases to better understand their pathogenesis and create new avenues for treatment.

Identifying key priorities for research to protect the consumer with food hypersensitivity: A UK Food Standards Agency Priority Setting Exercise

Introduction

Food hypersensitivity (FHS), including food allergy, coeliac disease and food intolerance, is a major public health issue. The Food Standards Agency (FSA), an independent UK Government department working to protect public health and consumers’ wider interests in food, sought to identify research priorities in the area of FHS.

Methods

A priority setting exercise was undertaken, using a methodology adapted from the James Lind Alliance—the first such exercise with respect to food hypersensitivity. A UK‐wide public consultation was held to identify unanswered research questions. After excluding diagnostics, desensitization treatment and other questions which were out of scope for FSA or where FSA was already commissioning research, 15 indicative questions were identified and prioritized by a range of stakeholders, representing food businesses, patient groups, health care and academia, local authorities and the FSA.

Results

295 responses were received during the public consultation, which were categorized into 70 sub‐questions and used to define 15 key evidence uncertainties (‘indicative questions’) for prioritization. Using the JLA prioritization framework, this resulted in 10 priority uncertainties in evidence, from which 16 research questions were developed. These could be summarized under the following 5 themes: communication of allergens both within the food supply chain and then to the end consumer (ensuring trust in allergen communication); the impact of socio‐economic factors on consumers with FHS; drivers of severe reactions; mechanism(s) underlying loss of tolerance in FHS; and the risks posed by novel allergens/processing.

Discussion

In this first research prioritization exercise for food allergy and FHS, key priorities identified to protect the food‐allergic public were strategies to help allergic consumers to make confident food choices, prevention of FHS and increasing understanding of socio‐economic impacts. Diagnosis and treatment of FHS was not considered in this prioritization.