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Li JC, Rotter NS, Stieb ES, Stockbridge JL, Theodorakakis MD, Shreffler WG. Utility of food allergy thresholds. Ann Allergy Asthma Immunol 2024; 132:321-327. [PMID: 38114041 DOI: 10.1016/j.anai.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023]
Abstract
Food allergy is a prevalent disease worldwide that is a significant quality-of-life burden, and accidental exposures to food allergens may elicit severe, life-threatening reactions such as anaphylaxis. The threshold level, or the dose that triggers an allergic reaction determined by oral food challenges, varies considerably among individuals suffering from food allergies. Moreover, IgE concentration, diversity, or function can only partially explain this variation in threshold; pathogenic effector TH2 cells have also been found to contribute to the eliciting dose. Though very sensitive to cofactors such as physical activity/stress, the threshold is a stable and reproducible feature of an individual's allergy over periods of many months, made clear in the past several years from treatment studies in which repeated threshold determination has been used as a treatment outcome; however, there also seem to be age-related changes at a population level. More routine determination of food allergy thresholds may help patients stratify risk to improve the management of their food allergy. Precautionary allergen labeling, such as "may contain" labels, often causes confusion since they are inconsistent and regularly contain little to trace allergen residues; thus, food products with such labeling may be unnecessarily avoided. Population-based eliciting dose levels have been determined in the literature; patients at lower risk with higher thresholds may be more confident with introducing foods with precautionary allergen labels. Understanding a patient's threshold level could aid in shared decision-making to determine the most suitable treatment options for patients, including the starting dose for oral immunotherapy and/or the use of biologics.
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Affiliation(s)
- Jennifer C Li
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy S Rotter
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Elisabeth S Stieb
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer L Stockbridge
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts
| | - Maria D Theodorakakis
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Wayne G Shreffler
- Food Allergy Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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Schaible A, Kabourek J, Elverson W, Venter C, Cox A, Groetch M. Precautionary Allergen Labeling: Avoidance for All? Curr Allergy Asthma Rep 2024; 24:81-94. [PMID: 38270804 DOI: 10.1007/s11882-024-01129-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE OF REVIEW Precautionary allergen labeling (PAL) suggests the risk of unintended allergen presence (UAP) in food but is unregulated in most countries and inconsistently applied by food manufacturers. This review evaluates the current use of PAL, its relevance to allergic consumers, and weighs possible advantages and disadvantages of avoiding products with PAL. RECENT FINDINGS In most countries, manufacturers are free to decide whether, when, and how to apply PAL resulting in inconsistencies and consumer confusion. Patients with food allergy often interpret PAL incorrectly and without guidance from their health care providers. Health care providers are also prone to misinterpreting PAL, indicating a need for better education. Consumers desire guidance on whether to avoid products with PAL or not. Until further regulatory guidance is available, shared decision-making between patient and provider is required to offer individualized, rather than one-size-fits-all, approaches to PAL.
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Affiliation(s)
- Allison Schaible
- Division of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA
| | - Jamie Kabourek
- Food Allergy Research and Resource Program, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Wendy Elverson
- Department of Clinical Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Carina Venter
- Section of Pediatric Allergy and Immunology, University of Colorado, Children's Hospital Colorado, Denver, Co, USA
| | - Amanda Cox
- Division of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA
| | - Marion Groetch
- Division of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA.
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La Vieille S, Hourihane JO, Baumert JL. Precautionary Allergen Labeling: What Advice Is Available for Health Care Professionals, Allergists, and Allergic Consumers? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:977-985. [PMID: 36682535 DOI: 10.1016/j.jaip.2022.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 01/21/2023]
Abstract
In most countries, the use of precautionary allergen labeling (PAL) is not governed by regulation. PAL was initially identified as a judicious risk management measure to address instances of "unavoidable" cross-contact with priority food allergens during food processing. However, PAL has gradually been devalued in part due to overuse and inconsistent application by the food industry. Currently, most food products do not contain detectable allergen residue or contain only low concentrations of residue of the allergens declared using PAL; however, occasionally, high concentrations of allergen residue are reported, rendering it an ineffective risk communication tool for allergic consumers. In this context, several reasons exist that make the consumption of products bearing a PAL statement not advisable for people with food allergies. The main reason is that the risk is generally not correlated with the statement used by manufacturers. Because of the increased use of PAL on prepackaged food products, and to maximize food choices for allergic individuals, health care professionals increasingly advise some patients considered to be "not highly allergic" to consume products bearing a PAL statement. This article explains why the consumption of products with PAL is not advisable without having a full clinical evaluation and knowledge that an allergen risk assessment has been conducted. It also discusses the perspectives for a better use of PAL on the basis of the recent Food and Agricultural Organization/World Health Organization recommendations on food allergens.
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Affiliation(s)
- Sébastien La Vieille
- Food Directorate, Health Canada, Ottawa, ON, Canada; Food Science Department, Laval University, Québec, QC, Canada.
| | | | - Joseph L Baumert
- Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, Neb
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Silvia D, Jérémie T, Povolo B, Gerdts J, Samuel Benrejeb G. Allergen management under a voluntary PAL regulatory framework – A survey of Canadian food processors. Heliyon 2022; 8:e11302. [DOI: 10.1016/j.heliyon.2022.e11302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
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Manny E, Dominguez SA, Barrère V, Théolier J, Godefroy SB. Allergen action levels for food industries as risk management tools for a better use of precautionary Allergen labelling. Food Control 2022. [DOI: 10.1016/j.foodcont.2021.108773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Miller TA, Koppelman SJ, Bird JA, Hernandez-Trujillo V, Thyagarajan A, Mack D, Chalil JM, Green TD, Baumert JL. Peanut cross-contamination in randomly selected baked goods. Ann Allergy Asthma Immunol 2022; 128:439-442. [PMID: 35131409 DOI: 10.1016/j.anai.2022.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The current standard of care for managing peanut allergy includes avoidance of peanut and use of injectable epinephrine; however, strict avoidance is difficult and accidental ingestion is common with potentially serious consequences. Despite vigilance and efforts to minimize the risk of accidental exposure, peanut protein cross-contamination continues to occur in a variety of foods, including baked goods. OBJECTIVE To assess and quantify the presence of peanut protein contamination in certain baked goods. METHODS Randomly selected baked goods were collected from bakeries in the New York and Miami metropolitan areas that sold a variety of ethnic cuisines. A second set of samples from the same bakeries was collected at least 1 week after to evaluate between-batch variability. Samples were sent to the Food Allergy Research and Resource Program to analyze peanut contamination by enzyme-linked immunosorbent assay. Consumption estimates were based on 2003 to 2010 National Health and Nutrition Examination Survey survey data. RESULTS Of 154 samples from 18 bakeries, 4 (2.6%) had detectable peanut contamination with peanut protein levels ranging from 0.1 mg/100 g to 650 mg/100 g. Consumption estimates for single occasion ingestion of a contaminated item ranged from 0.07 mg to 832 mg of peanut protein. CONCLUSION In this study, unintended peanut protein was present in a small, but not insignificant, proportion of baked goods, with the potential to trigger a reaction in individuals with peanut allergy. Some products contained high levels of unintended peanut protein. The current data support the potential for accidental exposure to peanut protein with its associated risk.
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Affiliation(s)
| | - Stef J Koppelman
- Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska-Lincoln, Lincoln, Nebraska; DBV Technologies, Montrouge, France.
| | - J Andrew Bird
- Department of Pediatrics, The University of Texas Southwestern, Dallas, Texas
| | - Vivian Hernandez-Trujillo
- Allergy and Immunology Care Center of South Florida, Division of Allergy & Immunology, Nicklaus Children's Hospital, Miami, Florida
| | | | - Douglas Mack
- McMaster University, Hamilton, Ontario, Canada; Halton Pediatric Allergy, Burlington, Ontario, Canada
| | - Joseph M Chalil
- DBV Technologies, Montrouge, France; Nova Southeastern University, Fort Lauderdale, Florida
| | - Todd D Green
- DBV Technologies, Montrouge, France; UPMC Children's Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska-Lincoln, Lincoln, Nebraska
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Tree Nuts and Peanuts as a Source of Beneficial Compounds and a Threat for Allergic Consumers: Overview on Methods for Their Detection in Complex Food Products. Foods 2022; 11:foods11050728. [PMID: 35267361 PMCID: PMC8909911 DOI: 10.3390/foods11050728] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 02/15/2022] [Accepted: 02/25/2022] [Indexed: 12/18/2022] Open
Abstract
Consumption of tree nuts and peanuts has considerably increased over the last decades due to their nutritional composition and the content of beneficial compounds. On the other hand, such widespread consumption worldwide has also generated a growing incidence of allergy in the sensitive population. Allergy to nuts and peanuts represents a global relevant problem, especially due to the risk of the ingestion of hidden allergens as a result of cross-contamination between production lines at industrial level occurring during food manufacturing. The present review provides insights on peanuts, almonds, and four nut allergens—namely hazelnuts, walnuts, cashew, and pistachios—that are likely to cross-contaminate different food commodities. The paper aims at covering both the biochemical aspect linked to the identified allergenic proteins for each allergen category and the different methodological approaches developed for allergens detection and identification. Attention has been also paid to mass spectrometry methods and to current efforts of the scientific community to identify a harmonized approach for allergens quantification through the detection of allergen markers.
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