Current tools measuring anxiety in parents of food-allergic children are inadequate

Systematic Review of the Incidence and/or Prevalence of Eating Disorders in Individuals With Food Allergies

BACKGROUND

Chronic diseases involving strict dietary adherence have been associated with an increased risk of eating disorders (EDs). This is the first systematic review investigating the rate of EDs among individuals with food allergies (FAs).

OBJECTIVE

To report the incidence, prevalence, and types of EDs in individuals with FAs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases for studies published to January 2022 that reported the prevalence or incidence of EDs in samples with immunoglobulin E (IgE) or non-IgE-mediated allergy. Risk of bias was assessed and evidence qualitatively synthesized.

RESULTS

From 1,180 papers identified, 9 met inclusion criteria. There were 4,161 adult and pediatric participants with IgE-mediated FAs or eosinophilic esophagitis. Avoidant/Restrictive Food Intake Disorder (ARFID) or anorexia nervosa/bulimia nervosa were the main EDs identified. The prevalence of EDs in samples with FA ranged from 0.8% to 62.9%. Among studies investigating IgE-mediated FA (n = 6), the prevalence of anorexia nervosa and/or bulimia nervosa ranged from 17.6 to 61%, ARFID was 62.9%, and unspecified EDs was 0.8% to 6%. Among samples with eosinophilic esophagitis (n = 3), ARFID prevalence ranged from 4.5% to 51%. Most studies were limited by small sample size, possible selection bias, and lack of diagnostic EDs tools validated for food allergic populations.

CONCLUSIONS

Eating disorders appear prevalent in individuals with FA; however, prevalence estimates varied widely. Large studies with healthy control groups and validated measures to identify EDs in individuals with FA are needed to accurately determine the prevalence of EDs.

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.

Cognitive-behavioral intervention for anxiety associated with food allergy in a clinical sample of children: Feasibility, acceptability, and proof-of-concept in children

BACKGROUND

Multiple reviews have identified a lack of evidence-based treatments for excessive anxiety in the context of food allergy (FAA) as an unmet need.

OBJECTIVE

To evaluate the feasibility, acceptability, and proof of concept of Food Allergy Bravery (FAB), a brief, novel, manualized cognitive-behavioral-based intervention for anxiety in a clinical sample of children with FAA.

METHODS

A total of 3 cohorts of children (aged 8 to 12 years) with clinically impairing FAA and their parents were offered a course of FAB delivered in a group format. Ratings of anxiety severity and quality of life were collected at pretreatment, posttreatment, and 2- to 4-month follow-up.

RESULTS

All families offered treatment completed the full course of FAB, attended at least 5 of 6 active treatment sessions, and rated the intervention as highly satisfactory. All children were rated as very much improved or much improved on the Clinician Global Impression scale at posttreatment. Anxiety severity scores on the Scale of Food Allergy Anxiety and the Scale of Child Anxiety-Related Emotional Disorders significantly declined per both child and parent reports. Scores on the Food Allergy Quality of Life Questionnaire-Parent Form were significantly improved. Gains were maintained at follow-up.

CONCLUSION

This is the first study of an outpatient manualized psychosocial treatment for FAA in a clinically ascertained sample of children. Findings provide initial evidence of feasibility, acceptability, and proof of concept for the FAB intervention protocol. Randomized controlled trials are needed.

Food-allergy-specific anxiety and distress in parents of children with food allergy: A systematic review

BACKGROUND

Parenting a child with food allergy (FA) can lead to impaired quality of life and family functioning. Anxiety is a critical component of FA-associated distress and a potential target for therapeutic intervention. This systematic review aimed to clarify the concept of FA-specific anxiety (FAA) and its antecedents, consequences, and correlates and to determine the extent to which existing FA-specific outcome measures capture symptoms of parental distress and FAA.

METHODS

MEDLINE, EMBASE, PsycINFO, and CENTRAL were searched for qualitative and quantitative studies examining distress or anxiety in parents of children with FA through August 2020. This review was registered with PROSPERO (CRD42020208316) and conducted in accordance with PRISMA guidelines.

RESULTS

Ninety-eight studies were included in the final narrative synthesis. Most participants were mothers, and reporting of demographic data was limited. Parents identified anxiety as the most burdensome form of FA-specific emotional distress. Several allergy-related factors as well as medical and psychosocial interventions were associated with reduced parental anxiety and distress. However, affective, cognitive, and behavioral dimensions of FAA were only partially addressed by existing measures for general anxiety symptoms and FA-specific parental factors.

CONCLUSIONS

FAA contributes to distress and functional impairment among parents of children with FA. Current FA-specific parent measures fail to adequately capture dimensions of FAA, suggesting that further work is needed to improve the assessment and monitoring of FAA and its impacts. Characterization of this construct represents an initial step in developing standardized methods for assessing and monitoring FAA in clinical populations.

Development of the Child- and Parent-Rated Scales of Food Allergy Anxiety (SOFAA)

BACKGROUND

Anxiety can be excessive and impairing in children with food allergy (FA). There is no accepted condition-specific measure of anxiety for this population.

OBJECTIVE

To evaluate the validity and reliability of new child- and parent-rated measures of FA-related anxiety in youth.

METHODS

Items for the Scale of Food Allergy Anxiety (SOFAA) were developed by a cognitive-behavioral therapist specializing in pediatric anxiety, in consultation with FA medical professionals and parents of children with FA. Dyads (n = 77) of children with FA (aged 8-18 years; 42.9% females) and their parents (95.5% females) completed full versions of the SOFAA (21 items; scored 0-4) via online survey.

RESULTS

The child-rated SOFFA-C mean score was 29.1 ± 18.3; the parent-rated SOFAA-P mean score was 33.9 ± 16.1. Higher scores indicate higher reported anxiety. Coefficient alphas were 0.94 and 0.92. Factor analyses and item-response theory analyses supported the creation of the 14-item SOFAA-C-brief and the 7-item SOFAA-P-brief, accounting for 93% and 79% of total variance, respectively. Correlations revealed strong convergence between child- and parent-report for both the full (r = 0.85) and brief (r = 0.79) versions. Correlations with a generic measure of child anxiety (Screen for Child Anxiety Related Disorders) and the Food Allergy Quality of Life Questionnaire ranged from moderate to strong, whereas those with a generic measure of child eating problems (About Your Child's Eating) were weak to moderate, supporting convergent and divergent validity. Scores of 48 dyads who completed SOFAAs at time 2 (mean, 16.0 days) appeared stable over time, supporting test-retest reliability.

CONCLUSIONS

The 21-item SOFAA-C and SOFAA-P are reliable and valid scales for measuring condition-specific anxiety in youth with FA. As shorter screening measures, the SOFAA-C-brief and the SOFAA-P-brief are also reliable and valid.

Development of the Food Allergy Anxiety Scale in an Adult Population: Psychometric Parameters and Convergent Validity

BACKGROUND

Food allergy (FA) affects up to 10% of young children and 2% to 3% of adults, and appears to be increasing in prevalence across the world. The adverse and growing impact of FAs warrants that closer attention is needed to the psychological mechanisms underlying FA and quality of life, to provide benefits for both clinicians and patients. One of these psychological mechanisms, frequently present in individuals struggling with FA, is anxiety.

OBJECTIVE

To provide an FA-specific measure to properly assess the impact of anxiety, the present research proposed the novel Food Allergy Anxiety Scale in an adult population.

METHODS

Two studies were conducted (n = 412), and the psychometric properties of the measure were extensively assessed through several robust statistical techniques (eg, exploratory factor analysis, confirmatory factor analysis, and item response theory).

RESULTS

Our findings indicated a reliable 1-factor structure, significantly associated with other constructs such as general anxiety, depression, and FA quality of life.

CONCLUSIONS

We are confident that the Food Allergy Anxiety Scale is a powerful tool to assess this specific role of FA within anxiety, which might lead to a better comprehension on how this psychological distress works, and consequently, the development of better strategies to reduce its impact.