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

Impact of Food Allergies on the Food Safety and Life Quality of Adults in Spain

Food allergies are increasingly frequent immune system reactions triggered by allergens present in food, which can affect quality of life. To investigate the impact of food allergies among Spanish adults and the influence of gender and age of diagnosis, an online survey using the shortened version of the Adult Food Allergy Quality of Life Questionnaire (FAQLQ) was conducted. A total of 134 participants with food allergies were enrolled in the exploratory study. Significant differences (p ≤ 0.050) were found in the perception of the emotional and social impact of food allergies on quality of life. Age of diagnosis (childhood, adolescence, or adulthood) had a greater influence on more variables than gender. Men reported greater fear of accidentally consuming something that could trigger an allergic reaction compared to women (p = 0.003), while women felt more excluded due to their allergies (p = 0.030). Overall, the perception of eating out was characterized by insecurity. The quality of life of individuals with food allergies could be improved through the use of pictograms on labels, menus, and increased training in the foodservice industry regarding allergens. Multiple additional investigations are recommended to generalize current findings.

Experiences and perceptions of people with celiac disease, food allergies and food intolerance when dining out

Introduction

Eating out is a common practice in modern society. Celiac disease (CeD) and food allergy (FA) are among the most common conditions responsible for adverse reactions to food. Despite their different origins, both require treatment with restrictive diets (avoidance of gluten and/or specific allergens) and this results posing similar challenges when eating out. Our objective was to learn about the experiences/perceptions of consumers with CeD and FA when dining out, as well as the challenges they face in food service environments.

Methods

An ad hoc questionnaire was used to record consumer perceptions, food service characteristics and resulting adverse reactions.

Results

377 individuals living in Santiago, Chile, provided complete information and were analyzed (160 CeD, 105 FA). 301 participants (79.8%) declared eating out, 33.6% reported experiencing an adverse reaction at least once while eating out. 94.4% of the 377 participants believed that the serving staff had little or no knowledge about his/her condition. Consumers reporting symptoms as severe adverse reactions were more common among celiac than allergic patients (p < 0.001).

Discussion

The study showed no significant differences based on consumer-related characteristics (p:NS). The consequences of eating out did not vary based on individual's data, including diagnosis, age, frequency of eating out, adverse reactions experienced, or intensity. These findings suggest that the most important determinants of risk associated with eating out are characteristics of the food service, like availability of information, staff training, and establishment's facilities like equipment available, exclusive utensils for customers with special dietary needs and kitchen and bathrooms organization.

Preventing food allergy fatalities

Fatal anaphylaxis to food is thankfully rare, but every death is a potentially avoidable tragedy. Usually, there will be a coronial inquest to establish the 'how and why' for each death. Reviewing these food allergy-related deaths identifies a number of common themes and risk factors. While some are non-modifiable (such as age, gender and ethnicity), others are and include delayed epinephrine administration and communication difficulties in allergen avoidance. This review highlights the key messages in food allergy-related fatality prevention for healthcare professionals and patients alike, and where available, we explain the evidence behind such recommendations. We describe the data behind the good practice points to facilitate their adoption in routine practice without generating additional anxiety for what is a comparatively rare event. We also propose an information leaflet for patients and carers, developed with patients and endorsed by two major allergy charities, to facilitate dissemination of the recommendations in this review.

Low dietary adherence after a positive food challenge in food allergic adults

BACKGROUND

After a positive food challenge (FC), patients receive dietary advice regarding avoidance of the culprit food. We examined the frequency and variables associated with dietary adherence after a positive FC in adults.

METHODS

In this prospective daily practice study, adults with a positive FC were included. After every FC, dietary advice was given consisting of three options: (1) strict avoidance, (2) avoidance but products with precautionary allergen labelling (PAL) allowed and (3) (small) amounts allowed. Questionnaires about dietary adherence and associated variables were completed prior to and 6 months after the FC(s).

RESULTS

41 patients (with 58 positive FCs) were included. Overall, patients adhered to the advised diet after 31% of the FCs. After 33 FCs, the advice was strict avoidance, whereof 82% followed a less strict diet. After 16 FCs, the advice was avoidance but products with PAL allowed, whereof 19% followed a less strict and 25% a stricter diet. In 9 FCs with the least strict advice, "(small) amounts allowed'', 67% followed a stricter diet. Three variables were associated with adherence: misremembering dietary advice, impaired health-related quality of life (HRQL) on domain "Emotional impact'' and the need for dietary change after the FC.

CONCLUSION

After one third of the positive FCs, patients adhered to the dietary advice. Variables associated with adherence were misremembering dietary advice, impaired HRQL on domain "Emotional impact'' and the need for dietary change after the FC. It seems important that healthcare professionals should more frequently apply adherence-enhancing strategies to improve dietary adherence.

hGLUTEN Tool: Measuring Its Social Impact Indicators

hGLUTEN is a technological solution capable of detecting gluten and spoiled food. We measured the social impact of the hGLUTEN tool using two Likert scale surveys with two groups: professionals (engineers/chefs) and end-users. These data have been assessed in accordance with the social impact indicators defined for the Key Impact Pathways introduced by the European Commission for Horizon Europe and the criteria of the Social Impact Open Repository (SIOR). A total of 85% of users, 100% of engineers and 68% of professional chefs consider it very relevant to participate and give their opinion in research projects, which shows the increasingly high level of involvement of the general population. A total of 88% of users were unaware of other applications that detect gluten and were more dependent on guidelines provided by allergy associations and expiry dates of foodstuffs. In addition, only 5% of professional chefs said they were aware of other technology capable of detecting gluten in food, which may indicate a large economic market and good commercialisation possibilities for the tool in the future. Finally, the inclusion of tools to motivate users to promote it has been identified as an area for improvement, which could mean that it should be made more visible in the media to increase its impact and influence.

The health implications of distrust in the food system: findings from the dimensions of trust in food systems scale (DOTIFS scale)

Background

Consumer trust in food systems is essential for consumers, food industry, policy makers and regulators. Yet no comprehensive tool for measuring consumer trust in food systems exists. Similarly, the impact that trust in the food system has on health-related food behaviours is yet to be empirically examined. The aim of this research was to develop a comprehensive instrument to measure trust in the food system (the Dimensions of Trust in Food Systems Scale (DOTIFS scale) and use it to explore whether trust in the food system impacts consumers’ health-related behaviours.

Methods

The DOTIFS scale was developed using sociological theories of trust and pre-existing instruments measuring aspects of trust. It was pilot tested and content validity was assessed with 85 participants. A mixed-methods exploration of the health-related behaviours of 18 conveniently sampled Australian consumers with differing trust scores determined by the DOTIFS scale was then conducted. During March–July 2019 shopping- and home-observations were used to assess participants’ food safety practices and exposure to public health fortification programs, while the CSIRO Healthy Diet Score determined their adherence to national dietary guidelines.

Results

The DOTIFS scale was found to have high comprehension, ease of use and content validity. Statistical analysis showed scale scores significantly trended as predicted by participants’ stated level of trust. Differences were found in the way individuals with more or less trust in the food system comply with national dietary guidelines, are exposed to public health fortification programs, and adhere to recommended food safety practices.

Conclusions

The DOTIFS scale is a comprehensive, sociologically- and empirically- informed assessment of consumer trust in food systems that can be self-administered online to large populations and used to measure changes in consumer trust over time. The differences in health-related behaviours between individuals with varying levels of trust warrant further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11349-9.

Poor understanding of allergen labelling by allergic and non-allergic consumers

Background

Understanding consumers’ interpretation of allergy information is crucial for effective food safety policies. We evaluated consumer understanding of allergy information on foods in controlled, experimental studies.

Method

Using 18 packaged foods, we evaluated consumer understanding of information about allergens in two experiments: First, a comparison of foods with no stated allergen versus allergen as a stated ingredient versus a precautionary allergen label (PAL); second, a comparison of three common variants of PAL. In each experiment, consumers with and without self‐reported food allergy were asked to estimate the risk of allergic reaction and to rate the comprehensibility of the allergen information. In the second experiment, consumers were also asked which form of PAL they preferred.

Results

Risk of reaction was assessed as high and low for foods with the allergen stated as ingredient, or without any mention of allergen. However, risk assessment for PAL varied and was judged as higher by non‐allergic than allergic participants (82% vs. 58%, p < .001). Understanding of risk associated with PAL also varied by health literacy (p < .001). Both allergic and non‐allergic consumers judged all forms of allergy information to be unclear, especially products with no allergy information for non‐allergic consumers. Products with a ‘Produced in a Factory’ PAL were perceived as less risky than ‘May contain’ or ‘Traces of’ PALs (p < .001), less than 40% of participants judged PAL information to be comprehensible, and participants preferred ‘May contain’ over the other PALs.

Conclusion

Both allergic and non‐allergic consumers find allergen information difficult to interpret on packaged foods and misunderstand PAL, incorrectly distinguishing different risk levels for different PAL wording. Clearer allergy information guidelines are called for, and the use of only one PAL wording is recommended.

Allergen labelling: Current practice and improvement from a communication perspective

BACKGROUND

Allergen information on product labels is crucial in food allergy management, though inadequacy in current labelling practices is one of the major causes for accidental reactions upon consuming prepacked food products.

OBJECTIVE

This study analyses current status of communicating allergen information on food labels and provides practical recommendations for improving the label format based on communication theory.

METHODS

Product labels (N 288) of seven food categories from private label products and brands were obtained at three retailers in the Netherlands. Information regarding the 14 EU-regulated allergens was evaluated by the frequency of emphasizing allergens in the ingredient list, use of precautionary allergen labelling (PAL), icons and an allergen information section. Effectiveness of communication was assessed evaluating readability and findability of information on allergens using principles of Gestalt and Cognitive Load theories.

RESULTS

As requested by EU regulation 1169/2011, emphasizing allergens in the ingredient list was almost 100%, all other presentations of information on allergens on labels was highly diverse. A separate allergen information section was present on most private label products. This section could, but not necessarily did, repeat allergens from the ingredient list and/or give a PAL. Brands often provided a PAL at the end of the ingredient list. Part of the products displayed an icon at different locations of the label. Label background, a lack of cohesion and variation in location of topics hamper the identification of relevant information on allergens by (allergic) consumers. Recommendations include a standardized order for mandatory and voluntary topics on the label and a separate allergen information section.

CONCLUSION AND CLINICAL RELEVANCE

Overall, consumers encounter a wide and inconsistent range in ways of presentation of allergen information on labels. Standardization according to basic design principles can improve usability and support safe food purchases for allergic consumers.

Understanding Precautionary Allergen Labeling (PAL) Preferences Among Food Allergy Stakeholders

BACKGROUND

Food allergy (FA) is an increasing public health concern in the United States, affecting approximately 8% of children and 11% of adults. The United States currently lacks clear requirements for the use of precautionary allergen labeling (PAL) on packaged foods, such as "may contain" or "made on shared equipment." This lack of specific governmental policy results in inconsistent labeling practices and confusion.

OBJECTIVE

This study aimed to understand current knowledge and preferences for PAL statements among FA stakeholders.

METHODS

A cross-sectional survey was sent to FA stakeholders. Descriptive statistics and associations from logistic regressions were used to assess respondents' knowledge of PAL policy, shopping habits, and preferences around PAL.

RESULTS

Of 3008 respondents, 24.2% were able to correctly answer 4 questions surrounding PAL policies. When asked about their shopping habits, the majority of respondents never purchase products with a "May contain traces of allergen" label (85.5%) in comparison with never purchasing products with a "Good manufacturing practices used to segregate ingredients in a facility that also processes allergen" label (35.0%). Their top preferences for a PAL statement were "Not suitable for people with 'blank' allergy" (29.3%) and "May contain" (22.1%). Health care provider discussions around PAL varied and were strongly associated with purchasing behaviors.

CONCLUSIONS

These results suggest that FA consumers are not aware of PAL policies and make decisions based on the words in the PAL. They prefer having clearer, more specific, and consistent labeling on products, indicating that explicit PAL policies are needed to allow customers to easily identify safe foods.

Non-Nutritive (Artificial) Sweetener Knowledge among University Students

This study determined non-nutritive sweetener (NNS; artificial sweetener) depth of knowledge among university health and science students. An online survey was delivered to 1248 science students and completed by 493 respondents (19.0 ± 2.2 years old), evaluating ability to provide an NNS description/definition, examples of NNS from memory, and evaluate NNS word familiarity with a click-drag-box to identify six NNS by chemical name (CN) and six NNS by trade name (TN), relative to six decoy NNS, six caloric sweeteners, and six food items (mean ± standard deviation). NNS definitions contained 1.1 ± 1.1 of four previously defined elements suggestive of knowledge depth, with highest scores among self-described non-NNS users and food ingredient label users. Knowledge depth was not correlated with gender, age, American College Test score, or history of weight loss attempts. Without prompting, respondents could name 0.9 ± 1.1 NNS from memory, with highest scores among self-described non-NNS users (1.4 ± 0.8) and food ingredient label users (1.4 ± 0.8). NNS example memory was not correlated with gender, age, ACT score, or history of weight loss attempts. With the click-drag-box exercise, NNS were correctly identified 4.9 ± 1.0 times by TN and significantly less by CN (3.9 ± 1.9 times). Decoy NNS were incorrectly identified as being a real NNS 4.7 ± 1.3 times, while caloric sweeteners and food items were incorrectly identified as NNS 1.7 ± 1.7 times and 1.0 ± 1.5 times, (TN and Decoy NNS > CN > caloric sweetener and food item). NNS knowledge among university students may be inadequate for understanding what NNS are, if they consume NNS, or whether NNS are important for dietary health.

Food allergen knowledge, attitude and practices among UK consumers: A structural modelling approach

Food allergies are becoming more prevalent and affect up to 1-2% of adults and 5-8% of children in the UK. This study investigated the food allergen knowledge, attitude towards food allergens and food allergy management practices among food allergic and intolerant consumers and/or their family members and carers. Questionnaires were distributed at three major Free From events in the UK in 2017 and 2018. Structural Equation Modelling (SEM) was used as a confirmatory technique to determine the model's validity. Cereals containing gluten, milk and eggs were the most common triggers reported by the consumers. Other trigger foods such as chocolate, garlic, maize, onions, red and white meat, spices, and fruits such as apples and cherries were also reported. Consumers demonstrated very good understanding on the severity of allergic reactions, prevention method and hidden egg ingredients. Overall, consumers were relatively good in the knowledge section. The participants were motivated in their personal allergen avoidance towards food allergens especially in checking food labels, preference for more free from product choices and handwashing. Consumers did not rely on dietary apps or social media to find out about allergen-free food products. Both knowledge and attitude did not translate into food allergy management practices. Significant correlation between knowledge and attitude was identified suggesting that as knowledge decreases, so will their attitude scores. This study suggests that targeted and systematic food allergy management topics and peer support could be used to improve consumers' knowledge and attitude to positively impact food allergen handling practices.

Comparing the eating out experiences of consumers seeking to avoid different food allergens

Background

Eating outside the home is challenging for consumers with food allergy (FA) and intolerance (FI) and lack of allergen information provision in eating out venues can lead to unnecessary restrictions. Following European legislation (2014) designed to improve allergen information provision, little is known about differences in information provision experienced by consumers seeking to avoid particular allergens, or how this impacts on their eating out experiences. This study compared the information provision that consumers with FA/FI to different allergens experience when eating out.

Methods

Using mixed methods, participants were recruited from across the UK and took part in self-report surveys or in-depth interviews. Surveys were completed by 232 participants avoiding either gluten (n = 66), nuts (peanuts/tree nuts) (n = 94), or milk (n = 74), and responses were subject to quantitative analyses. Interviews were carried out with 49 participants avoiding either gluten (n = 13), nuts (n = 14), milk (n = 13) or a combination of these allergens (n = 9), and analysed using the framework approach.

Results

Although general improvements in information provision following the legislation were reported, variations in provision between allergen groups led participants seeking to avoid milk to conclude that their dietary needs were less well-understood and seen as less important. These perceptions were reflected in a reluctance to involve eating out venue staff in deliberations about the potential for milk-free meal options.

Conclusions

The provision of visual indicators of the presence of milk and of staff trained in allergen-awareness would improve the eating out experiences of consumers seeking to avoid milk. Medical professions can play a key role in encouraging these patients to pursue their right to make enquiries about allergens in order to avoid accidental milk ingestion when eating out.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6117-y) contains supplementary material, which is available to authorized users.

Determination of food allergens by LC-MS: Impacts of sample preparation, food matrix, and thermal processing on peptide detectability and quantification

Food allergies are a growing worldwide concern and the contamination of products with food allergens represents a significant health risk to allergic consumers. With the introduction of reference doses, quantitative methods are needed for the monitoring of allergen levels, and the potential of LC-MS/MS is of hugely growing interest. In this study, we demonstrate that relevant food matrices (bakery products and chocolates) and thermal food processing substantially influence the quantification of 18 marker peptides from various nut and peanut allergens via targeted proteomics. In addition, we characterize the individual release kinetics of marker peptides and provide examples for metastable marker peptide candidates. Matrix recovery rates overall ranged between 15 and 250% with the observed variation being linked to the individual peptide structure as well as to specific matrix interferences. In contrast, thermal processing considerably influences the detectability of allergens on the protein level as different marker peptides from the identical parent allergen are similarly affected, leading to a loss in signal of up to 83% in extreme cases after a 45-min simulated baking. Provided data are finally used for evaluation of different calibrators as well as the overall potential and challenges of LC-MS for the absolute quantification of food allergens. SIGNIFICANCE: With the scientific discussion moving towards a risk-based management of food allergens, including the establishment of threshold doses, robust methods for the absolute quantification of allergens in food samples are urgently needed. Because the currently used antibody- and DNA-based technologies show severe limitations in terms of specificity and reproducibility, LC-MS has emerged as a promising alternative. Its application to absolute quantification, however, first requires an understanding of the various impacts that affect quantification results, including different food matrices, sample preparation, and thermal processing of foodstuffs. Knowledge of these factors, which are assessed as part of a comprehensive survey in this study, is also an important prerequisite to evaluate means of calibration for an LC-MS-based quantification of food allergens.

Consumer-friendly food allergen detection: moving towards smartphone-based immunoassays

In this critical review, we provide a comprehensive overview of immunochemical food allergen assays and detectors in the context of their user-friendliness, through their connection to smartphones. Smartphone-based analysis is centered around citizen science, putting analysis into the hands of the consumer. Food allergies represent a significant worldwide health concern and consumers should be able to analyze their foods, whenever and wherever they are, for allergen presence. Owing to the need for a scientific background, traditional laboratory-based detection methods are generally unsuitable for the consumer. Therefore, it is important to develop simple, safe, and rapid assays that can be linked with smartphones as detectors to improve user accessibility. Smartphones make excellent detection systems because of their cameras, embedded flash functions, portability, connectivity, and affordability. Therefore, this review has summarized traditional laboratory-based methods for food allergen detection such as enzyme-linked-immunosorbent assay, flow cytometry, and surface plasmon resonance, and the potential to modernize these methods by interfacing them with a smartphone readout system, based on the aforementioned smartphone characteristics. This is the first review focusing on smartphone-based food-allergen detection methods designed with the intention of being consumer-friendly. Graphical abstract A smartphone-based food allergen detection system in three easy steps (1) sample preparation, (2) allergen detection on a smartphone using antibodies, which then transmits the data wirelessly, (3) analytical results sent straight to smartphone.

A Smartphone App to Reduce Sugar-Sweetened Beverage Consumption Among Young Adults in Australian Remote Indigenous Communities: Design, Formative Evaluation and User-Testing

BACKGROUND

The disproportionate burden of noncommunicable disease among Indigenous Australians living in remote Indigenous communities (RICs) is a complex and persistent problem. Smartphones are increasingly being used by young Indigenous adults and therefore represent a promising method to engage them in programs seeking to improve nutritional intake.

OBJECTIVE

This study aimed to consult RIC members to inform the content of a smartphone app that can be used to monitor and reduce sugar-sweetened beverage intake in RICs.

METHODS

The study was conducted in two phases. The formative phase involved a simulated grocery selection activity with think aloud ("think aloud shop"), a semistructured interview, a questionnaire outlining current smartphone and app use, and a paper prototyping activity. A preliminary end-user testing phase involved a think aloud prototype test and a semistructured interview regarding user satisfaction. Convenience sampling was used to recruit 20 18- to 35-year-old smartphone users for each phase from two RICs in the Northern Territory, Australia. Thematic analysis of transcribed audio recordings was used to identify determinants of food choice from the think aloud shop; themes related to the Theory of Planned Behavior (TPB) from the eating behaviors interview; and usability, comprehension, and satisfaction with the app from the preliminary end-user testing.

RESULTS

Smartphone use in RICs is currently different to that found in urban environments; in particular, extremely low use of Facebook, restricted variety of phone types, and limited Internet access. Findings regarding promoting app engagement indicate that utilizing an opt-in approach to social features such as leader boards and team challenges is essential. The inclusion of games was also shown to be important for satisfaction, as were the use of audio features, contextually embedded dissemination, and streamlined app design for comprehension in this target group.

CONCLUSIONS

This research provides critical insights and concrete recommendations for the development of lifestyle improvement apps targeted toward disadvantaged young adults in nonurban settings, specifically RICs. It serves as a framework for future app development projects using a consultative user-centered design approach, supporting calls for the increased use of this strategy in app development.

MRM3-based LC-MS multi-method for the detection and quantification of nut allergens

Food allergies have become a global challenge to food safety in industrialized countries in recent years. With governmental monitoring and legislation moving towards the establishment of threshold allergen doses, there is a need for sensitive and quantitative analytical methods for the determination of allergenic food contaminants. Targeted proteomics employing liquid chromatography-mass spectrometry (LC-MS) has emerged as a promising technique that offers increased specificity and reproducibility compared to antibody and DNA-based technologies. As the detection of trace levels of allergenic food contaminants also demands excellent sensitivity, we aimed to significantly increase the analytical performance of LC-MS by utilizing multiple reaction monitoring cubed (MRM³) technology. Following a bottom-up proteomics approach, including a straightforward sample preparation process, 38 MRM³ experiments specific to 18 proteotypic peptides were developed and optimized. This permitted the highly specific identification of peanut, almond, cashew, hazelnut, pistachio, and walnut. The analytical performance of the method was assessed for three relevant food matrices with different chemical compositions. Limits of detection were around 1 μg/g or below in fortified matrix samples, not accounting for the effects of food processing. Compared to an MRM-based approach, the MRM³-based method showed an increase in sensitivity of up to 30-fold. Regression analysis demonstrated high linearity of the MRM³ signal in spiked matrix samples together with robust intersample reproducibility, confirming that the method is highly applicable for quantitative purposes. To the best of our knowledge, we describe here the most sensitive LC-MS multi-method for food allergen detection thus far. In addition, this is the first study that systematically compares MRM³ with MRM for the analysis of complex foods. Graphical abstract Allergen detection by MRM³.

Consumer Preferences for Written and Oral Information about Allergens When Eating Out

Background

Avoiding food allergens when eating outside the home presents particular difficulties for food allergic (FA) and intolerant (FI) consumers and a lack of allergen information in restaurants and takeaways causes unnecessary restrictions. Across Europe, legislation effective from December 2014, aims to improve allergen information by requiring providers of non-prepacked foods to supply information related to allergen content within their foods.

Methods

Using in-depth interviews with 60 FA/FI adults and 15 parents/carers of FA/FI children, we aimed to identify FA/FI consumers’ preferences for written and/or verbal allergen information when eating out or ordering takeaway food.

Results

A complex and dynamic set of preferences and practices for written and verbal allergen information was identified. Overwhelmingly, written information was favoured in the first instance, but credible personal/verbal communication was highly valued and essential to a good eating out experience. Adequate written information facilitated implicit trust in subsequent verbal information. Where written information was limited, FA/FIs depended on social cues to assess the reliability of verbal information resources, and defaulted to tried and tested allergen avoidance strategies when these were deemed unreliable.

Conclusion

Understanding the subtle negotiations and difficulties encountered by FA/FIs when eating out can serve as a guide for legislators and food providers; by encouraging provision of clear written and verbal allergen information, and training of proactive, allergen-aware staff. This, in tandem with legal requirements for allergen information provision, paves the way for FA/FIs to feel more confident in eating out choices; and to experience improved eating out experiences.

Quality of life in patients with food allergy

Food allergy has increased in developed countries and can have a dramatic effect on quality of life, so as to provoke fatal reactions. We aimed to outline the socioeconomic impact that food allergy exerts in this kind of patients by performing a complete review of the literature and also describing the factors that may influence, to a greater extent, the quality of life of patients with food allergy and analyzing the different questionnaires available. Hitherto, strict avoidance of the culprit food(s) and use of emergency medications are the pillars to manage this condition. Promising approaches such as specific oral or epicutaneous immunotherapy and the use of monoclonal antibodies are progressively being investigated worldwide. However, even that an increasing number of centers fulfill those approaches, they are not fully implemented enough in clinical practice. The mean annual cost of health care has been estimated in international dollars (I$) 2016 for food-allergic adults and I$1089 for controls, a difference of I$927 (95 % confidence interval I$324–I$1530). A similar result was found for adults in each country, and for children, and interestingly, it was not sensitive to baseline demographic differences. Cost was significantly related to severity of illness in cases in nine countries. The constant threat of exposure, need for vigilance and expectation of outcome can have a tremendous impact on quality of life. Several studies have analyzed the impact of food allergy on health-related quality of life (HRQL) in adults and children in different countries. There have been described different factors that could modify HRQL in food allergic patients, the most important of them are perceived disease severity, age of the patient, peanut or soy allergy, country of origin and having allergy to two or more foods. Over the last few years, several different specific Quality of Life questionnaires for food allergic patients have been developed and translated to different languages and cultures. It is important to perform lingual and cultural translations of existent questionnaires in order to ensure its suitability in a specific region or country with its own socioeconomic reality and culture. Tools aimed at assessing the impact of food allergy on HRQL should be always part of the diagnostic work up, in order to provide a complete basal assessment, to highlight target of intervention as well as to evaluate the effectiveness of interventions designed to cure food allergy. HRQL may be the only meaningful outcome measure available for food allergy measuring this continuous burden.

Frequency, severity and causes of unexpected allergic reactions to food: a systematic literature review

Food allergic patients have to deal with an avoidance diet. Confusing labelling terms or precautionary labels can result in misinterpretation and risk-taking behaviour. Even those patients that strictly adhere to their diet experience (sometimes severe) unexpected allergic reactions to food. The frequency, severity and causes of such reactions are unknown. The objective of this review was to describe the frequency, severity and causes of unexpected allergic reactions to food in food allergic patients aged > 12 years, in order to develop improved strategies to deal with their allergy. A systematic review was carried out by two researchers, in six electronic databases (CINAHL, Cochrane, EMBASE, Medline, Psychinfo and Scopus). The search was performed with keywords relating to the frequency, severity and causes of unexpected allergic reactions to food. This resulted in 24 studies which met the inclusion criteria; 18 observational and six qualitative studies. This review shows that knowledge about the frequency of unexpected reactions is limited. Peanut, nuts, egg, fruit/vegetables and milk are the main causal foods. Severe reactions and even fatalities occur. Most reactions take place at home, but a significant number also take place when eating at friends' houses or in restaurants. Labelling issues, but also attitude and risky behaviour of patients can attribute to unexpected reactions. We conclude that prospective studies are needed to get more insight in the frequency, severity, quantity of unintended allergen ingested and causes of unexpected allergic reactions to food, to be able to optimize strategies to support patients in dealing with their food allergy. Although the exact frequency is not known, unexpected reactions to food occur in a significant number of patients and can be severe. For clinical practice, this means that patient education and dietary instructions are necessary.

Quality of life in the setting of anaphylaxis and food allergy

The diagnosis of a food allergy generally has a considerable impact on patients. Not does it result in dietary restrictions, it is often also associated with a constant threat scenario, given the risk of sudden allergic reactions, including life-threatening anaphylaxis. It is essential for patients to receive training on how to deal with emergency situations and make the correct decision regarding the use of emergency medication. Severe allergic reactions occur only rarely if patients are well informed. However, the fear of allergic reactions results in a significant impairment in quality of life (QoL).

In recent years, numerous studies have been carried out on QoL in food-allergy and anaphylaxis patients. These studies provide insight into patient behaviour in everyday life. More importantly, by means of targeted and specific counselling, they also make it possible to reduce adverse effects on QoL and improve avoidance behaviour and compliance in terms of the requisite emergency measures.

The present article summarizes the available data and formulates recommendations aimed at improving the care of food-allergy patients in terms of QoL and compliance.

EAACI Food Allergy and Anaphylaxis Guidelines. Protecting consumers with food allergies: understanding food consumption, meeting regulations and identifying unmet needs

Individuals suffering from IgE-mediated food allergy usually have to practise life-long food allergen avoidance. This document aims to provide an overview of recent evidence-based recommendations for allergen risk assessment and management in the food industry and discusses unmet needs and expectations of the food allergic consumer in that context. There is a general duty of care on the food industry and obligations in European Union legislation to reduce and manage the presence of allergens alongside other food hazards. Current evidence enables quantification of allergen reference doses used to set-up reliable food safety management plans for some foods. However, further work is required to include a wider variety of foods and to understand the impact of the food matrix as well as additional factors which affect the progression and severity of symptoms as a function of dose. Major concerns have been raised by patients, carers and patient groups about the use of precautionary 'may contain' labelling to address the issue of unintended presence of allergens; these therefore need to be reconsidered. New and improved allergen detection methods should be evaluated for their application in food production. There is an urgent requirement for effective communication between healthcare professionals, patient organizations, food industry representatives and regulators to develop a better approach to protecting consumers with food allergies.

Precautionary labelling of foods for allergen content: are we ready for a global framework?

Food allergy appears to be on the rise with the current mainstay of treatment centred on allergen avoidance. Mandatory allergen labelling has improved the safety of food for allergic consumers. However an additional form of voluntary labelling (termed precautionary allergen labelling) has evolved on a wide range of packaged goods, in a bid by manufacturers to minimise risk to customers, and the negative impact on business that might result from exposure to trace amounts of food allergen present during cross-contamination during production. This has resulted in near ubiquitous utilisation of a multitude of different precautionary allergen labels with subsequent confusion amongst many consumers as to their significance. The global nature of food production and manufacturing makes harmonisation of allergen labelling regulations across the world a matter of increasing importance. Addressing inconsistencies across countries with regards to labelling legislation, as well as improvement or even banning of precautionary allergy labelling are both likely to be significant steps forward in improved food safety for allergic families. This article outlines the current status of allergen labelling legislation around the world and reviews the value of current existing precautionary allergen labelling for the allergic consumer. We strongly urge for an international framework to be considered to help roadmap a solution to the weaknesses of the current systems, and discuss the role of legislation in facilitating this.

Assessing the efficacy of oral immunotherapy for the desensitisation of peanut allergy in children (STOP II): a phase 2 randomised controlled trial

BACKGROUND

Small studies suggest peanut oral immunotherapy (OIT) might be effective in the treatment of peanut allergy. We aimed to establish the efficacy of OIT for the desensitisation of children with allergy to peanuts.

METHODS

We did a randomised controlled crossover trial to compare the efficacy of active OIT (using characterised peanut flour; protein doses of 2-800 mg/day) with control (peanut avoidance, the present standard of care) at the NIHR/Wellcome Trust Cambridge Clinical Research Facility (Cambridge, UK). Randomisation (1:1) was by use of an audited online system; group allocation was not masked. Eligible participants were aged 7-16 years with an immediate hypersensitivity reaction after peanut ingestion, positive skin prick test to peanuts, and positive by double-blind placebo-controlled food challenge (DBPCFC). We excluded participants if they had a major chronic illness, if the care provider or a present household member had suspected or diagnosed allergy to peanuts, or if there was an unwillingness or inability to comply with study procedures. Our primary outcome was desensitisation, defined as negative peanut challenge (1400 mg protein in DBPCFC) at 6 months (first phase). Control participants underwent OIT during the second phase, with subsequent DBPCFC. Immunological parameters and disease-specific quality-of-life scores were measured. Analysis was by intention to treat. Fisher's exact test was used to compare the proportion of those with desensitisation to peanut after 6 months between the active and control group at the end of the first phase. This trial is registered with Current Controlled Trials, number ISRCTN62416244.

FINDINGS

The primary outcome, desensitisation, was recorded for 62% (24 of 39 participants; 95% CI 45-78) in the active group and none of the control group after the first phase (0 of 46; 95% CI 0-9; p<0·001). 84% (95% CI 70-93) of the active group tolerated daily ingestion of 800 mg protein (equivalent to roughly five peanuts). Median increase in peanut threshold after OIT was 1345 mg (range 45-1400; p<0·001) or 25·5 times (range 1·82-280; p<0·001). After the second phase, 54% (95% CI 35-72) tolerated 1400 mg challenge (equivalent to roughly ten peanuts) and 91% (79-98) tolerated daily ingestion of 800 mg protein. Quality-of-life scores improved (decreased) after OIT (median change -1·61; p<0·001). Side-effects were mild in most participants. Gastrointestinal symptoms were, collectively, most common (31 participants with nausea, 31 with vomiting, and one with diarrhoea), then oral pruritus after 6·3% of doses (76 participants) and wheeze after 0·41% of doses (21 participants). Intramuscular adrenaline was used after 0·01% of doses (one participant).

INTERPRETATION

OIT successfully induced desensitisation in most children within the study population with peanut allergy of any severity, with a clinically meaningful increase in peanut threshold. Quality of life improved after intervention and there was a good safety profile. Immunological changes corresponded with clinical desensitisation. Further studies in wider populations are recommended; peanut OIT should not be done in non-specialist settings, but it is effective and well tolerated in the studied age group.

FUNDING

MRC-NIHR partnership.

Characteristics and purchasing behaviours of food-allergic consumers and those who buy food for them in Great Britain

BACKGROUND

Buying behaviours of food-allergic consumers can affect the risk they incur. An online survey was undertaken to understand the characteristics and buying behaviours of food-allergic consumers in Great Britain (GB) and people buying food for them.

METHODS

Descriptive study of food-allergic individuals in GB and their buying behaviours, based on a survey of 500 food-allergic consumers and 500 people buying for allergic individuals.

RESULTS

Fruit and vegetables were the most commonly mentioned food allergens for adults, cows' milk in school-age children and eggs in younger children. 45% of respondents reported a formal diagnosis, almost half (48%) by a specialist. Significantly (P < 0.0001) more respondents reporting severe symptoms were likely to be formally diagnosed, but most reactions remained unreported. Nearly 2/3 of respondents always read product labels first time, however only 1/3 on every occasion. Only a third of respondents always avoided products with 'may contain' labels. Respondents reporting severe symptoms, albeit still a minority, showed significantly (P = 0.0026) more cautious buying behaviours.

CONCLUSIONS

Although self-reported, the pattern of food allergy reflects other studies. A minority of food-allergic individuals in GB, even among those reporting severe symptoms, have a formal diagnosis and most never come to the attention of health services, suggesting that food allergies are under-estimated while more severe reactors are over-represented in GB clinic populations. A substantial proportion of respondents regularly take risks when purchasing food including those reporting severe reactions, confirming that current application of precautionary labelling to mitigate and communicate risk is of limited effectiveness. Furthermore the failure of most food-allergic consumers to read labels on every occasion highlights the importance of thinking beyond legal compliance when designing labels, for example when adding an allergen to a product that previously did not contain it, the change should be flagged on the front of the pack to alert allergic consumers.

Beyond labelling: what strategies do nut allergic individuals employ to make food choices? A qualitative study

Objective

Food labelling is an important tool that assists people with peanut and tree nut allergies to avoid allergens. Nonetheless, other strategies are also developed and used in food choice decision making. In this paper, we examined the strategies that nut allergic individuals deploy to make safe food choices in addition to a reliance on food labelling.

Methods

Three qualitative methods: an accompanied shop, in-depth semi-structured interviews, and the product choice reasoning task – were used with 32 patients that had a clinical history of reactions to peanuts and/or tree nuts consistent with IgE-mediated food allergy. Thematic analysis was applied to the transcribed data.

Results

Three main strategies were identified that informed the risk assessments and food choice practices of nut allergic individuals. These pertained to: (1) qualities of product such as the product category or the country of origin, (2) past experience of consuming a food product, and (3) sensory appreciation of risk. Risk reasoning and risk management behaviours were often contingent on the context and other physiological and socio-psychological needs which often competed with risk considerations.

Conclusions

Understanding and taking into account the complexity of strategies and the influences of contextual factors will allow healthcare practitioners, allergy nutritionists, and caregivers to advise and educate patients more effectively in choosing foods safely. Governmental bodies and policy makers could also benefit from an understanding of these food choice strategies when risk management policies are designed and developed.

Application of scientific criteria to food allergens of public health importance

Scientific criteria for identifying allergenic foods of public health importance (Björkstén, B., Crevel, R., Hischenhuber, C., Løvik, M., Samuels, F., Strobel, S., Taylor, S.L., Wal, J.-M., Ward, R., 2008. Criteria for identifying allergenic foods of public health importance. Regulatory Toxicology and Pharmacology 51(1), 42-52) have been further refined to incorporate an assessment of the strength of available scientific evidence (van Bilsen, J.H., Ronsmans, S., Crevel, R.W., Rona, R.J., Przyrembel, H., Penninks, A.H., Contor, L., Houben, G.F., 2011. Evaluation of scientific criteria for identifying allergenic food of public health importance. Regulatory Toxicology and Pharmacology 60, 281-289). A multi-disciplinary group was invited to critically test the refined approach. They independently evaluated selected publications on coconut, soy and/or peanut allergy, scored them using the newly developed level of evidence criteria, and debated proposed approaches for combining and utilising the scores to measure the overall impact of an allergen in public health impact assessments. The evaluation of selected publications using the modified criteria produced a relatively consistent result across the experts. These refined criteria were judged to be a way forward for the identification of allergenic foods of public health importance, and for prioritisation of allergen risk management and future data gathering. The debate to combine available evidence when assessing whether an allergenic food is of sufficient public health importance to warrant active management led to proposals on how to weight and combine evidence on allergen severity, potency and prevalence. The refined criteria facilitate a debate to find a meaningful sequence of steps to summarise the available information in relation to a food allergen.

Factors influencing food choices of food-allergic consumers: findings from focus groups

BACKGROUND

Up to 35% of the population modify their diet for adverse reactions to food. This study described the food choice behaviour of diagnosed food-allergic (DFA), self-reported food-allergic or intolerant (SFA) and nonfood-allergic (NFA) consumers, and explored differences between them.

METHODS

Six focus groups with adults (n = 44) were conducted. Data analysis was performed using thematic content analysis.

RESULTS

Compared to NFA participants, DFA consumers were deprived of satisfaction and pleasure from foods, experienced difficulties finding safe foods and had to be organized with eating. SFA participants faced similar problems, but to a lesser degree; their food choices were strongly influenced by emotional factors or health awareness.

CONCLUSION

Food-allergic consumers' food choices are influenced by a number of factors that differ to those of NFA consumers. It is therefore important to offer people with food allergies or intolerances advice that goes beyond how to avoid allergens.

[Hidden allergens in processed food. The consumer perspective]

Despite improved allergen-labeling and careful avoidance strategies, hidden allergens in food are a substantial risk for unintended reactions in food allergy sufferers. Unpublished data from a survey of the German Allergy and Asthma Association (Deutscher Allergie- und Asthmabund, DAAB) show that 85% of 738 questioned food allergic patients have experienced at least one allergic reaction from each prepacked products as well as food sold loose. Almost half of the participants said to have not received information of a food allergen as an ingredient or possible trace on the label. Different possibilities are discussed under which food allergens can be hidden in processed products, like incomprehensible labeling, labeling gaps, unexpected occurrence of allergens as well as cross contaminations or allergens in loose products. To each of the seven highlighted sources of hidden allergens in food, practical examples are given as well as proposals for the improvement of the situation from consumer view. The aim is to indicate possibilities and measures for politics and industry by which allergic consumers and their social circle are able to make an informed choice concerning the safe consumption of a certain product and to protect themselves from unintentional reactions.

The strategies that peanut and nut-allergic consumers employ to remain safe when travelling abroad

BACKGROUND

An understanding of the management strategies used by food allergic individuals is needed as a prerequisite to improving avoidance and enhancing quality of life. Travel abroad is a high risk time for severe and fatal food allergic reactions, but there is paucity of research concerning foreign travel. This study is the first to investigate the experiences of, and strategies used by peanut and tree nut allergic individuals when travelling abroad.

METHODS

Thirty-two adults with a clinical history of reaction to peanuts or tree nuts consistent with IgE-mediated allergy participated in a qualitative interview study.

RESULTS

Travel abroad was considered difficult with inherent risks for allergic individuals. Many participants recounted difficulties with airlines or restaurants. Inconsistency in managing allergen avoidance by airlines was a particular risk and a cause of frustration to participants. Individuals used a variety of strategies to remain safe including visiting familiar environments, limiting their activities, carrying allergy information cards in the host language, preparing their own food and staying close to medical facilities.

CONCLUSIONS

Participants used a variety of allergen avoidance strategies, which were mostly extensions or modifications of the strategies that they use when eating at home or eating-out in the UK. The extended strategies reflected their recognition of enhanced risk during travel abroad. Their risk assessments and actions were generally well informed and appropriate. A need for airline policy regarding allergy to be declared and adhered to is needed, as is more research to quantify the true risks of airborne allergens in the cabin. Recommendations arising from our study are presented.

What factors affect the carriage of epinephrine auto-injectors by teenagers?

Background

Teenagers with allergies are at particular risk of severe and fatal reactions, but epinephrine auto-injectors are not always carried as prescribed. We investigated barriers to carriage.

Methods

Patients aged 12-18 years old under a specialist allergy clinic, who had previously been prescribed an auto-injector were invited to participate. Semi-structured interviews explored the factors that positively or negatively impacted on carriage.

Results

Twenty teenagers with food or venom allergies were interviewed. Only two patients had used their auto-injector in the community, although several had been treated for severe reactions in hospital. Most teenagers made complex risk assessments to determine whether to carry the auto-injector. Most but not all decisions were rational and were at least partially informed by knowledge. Factors affecting carriage included location, who else would be present, the attitudes of others and physical features of the auto-injector. Teenagers made frequent risk assessments when deciding whether to carry their auto-injectors, and generally wanted to remain safe. Their decisions were complex, multi-faceted and highly individualised.

Conclusions

Rather than aiming for 100% carriage of auto-injectors, which remains an ambitious ideal, personalised education packages should aim to empower teenagers to make and act upon informed risk assessments.

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.