Finding a Path to
Safety in Food Allergy
Assessment of the Global Burden,
Causes, Prevention, Management,
and Public Policy
Committee on Food Allergies: Global Burden, Causes, Treatment,
Prevention, and Public Policy
Food and Nutrition Board
Health and Medicine Division
Virginia A. Stallings and Maria P. Oria, Editors
A Report of
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This activity was supported by federal sponsors: the Food and Drug Administration (Contract No. HHSP233201400020B/HHSP23337025), the Food and Nutrition Service of the U.S. Department of Agriculture (Grant # FS_NAS_IOM_FY2015_01), and the National Institute of Allergy and Infectious Diseases; and nonfederal sponsors: the Asthma and Allergy Foundation of America, the Egg Nutrition Center, Food Allergy Research and Education, the International Life Sciences Institute North America, the International Tree Nut Council Nutrition Research & Education Foundation, the National Dairy Council, the National Peanut Board, and the Seafood Industry Research Fund. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
Library of Congress Cataloging-in-Publication Data
Names: National Academies of Sciences, Engineering, and Medicine (U.S.). Committee on Food Allergies: Global Burden, Causes, Treatment, Prevention, and Public Policy, author. | Stallings, Virginia A., editor. | Oria, Maria, editor. | National Academies of Sciences, Engineering, and Medicine (U.S.), issuing body.
Title: Finding a path to safety in food allergy : assessment of the global burden, causes, prevention, management, and public policy / Committee on Food Allergies: Global Burden, Causes, Treatment, Prevention, and Public Policy, Food and Nutrition Board, Health and Medicine Division ; Virginia A. Stallings and Maria Oria, editors.
Description: Washington, DC : The National Academies Press,  | Includes bibliographical references.
Identifiers: LCCN 2016052811| ISBN 9780309450317 (pbk.) | ISBN 0309450314 (pbk.) | ISBN 9780309450324 (pdf)
Subjects: | MESH: Food Hypersensitivity—prevention & control | Food Hypersensitivity—etiology | Food Hypersensitivity—epidemiology | Health Policy
Classification: LCC RC596 | NLM WD 310 | DDC 616.97/5—dc23 LC record available at https://lccn.loc.gov/2016052811
Digital Object Identifier: 10.17226/23658
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Printed in the United States of America
Suggested Citation: National Academies of Sciences, Engineering, and Medicine. 2017. Finding a path to safety in food allergy: Assessment of the global burden, causes, prevention, management, and public policy. Washington, DC: The National Academies Press. doi: 10.17226/23658.
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COMMITTEE ON FOOD ALLERGIES: GLOBAL BURDEN, CAUSES, TREATMENT, PREVENTION, AND PUBLIC POLICY
VIRGINIA A. STALLINGS (Chair), Professor of Pediatrics, Perlman School of Medicine, The Children’s Hospital of Philadelphia
KATRINA ALLEN, Professor, University of Melbourne, and Director, Centre of Food and Allergy Research, Murdoch Children’s Research Institute
A. WESLEY BURKS, Curnen Distinguished Professor, Executive Dean, University of North Carolina School of Medicine
NANCY R. COOK, Professor, Division of Preventive Medicine, Department of Medicine, Harvard Medical School
SHARON M. DONOVAN, Professor and Melissa M. Noel Endowed Chair in Nutrition and Health, University of Illinois at Urbana-Champaign
STEPHEN J. GALLI, Mary Hewitt Loveless, M.D. Professor, Stanford University School of Medicine
BERNARD GUYER, Zanvyl Kreiger Professor of Children’s Health Emeritus, Johns Hopkins University
GIDEON LACK, Head of the Clinical Academic Paediatric Allergy Service, King’s College London Guy’s & St. Thomas’ National Health Service Foundation Trust
ANN S. MASTEN, Regents Professor, Irving B. Harris Professor of Child Development, University of Minnesota, Minneapolis
JOSE M. ORDOVAS, Senior Scientist and Director, Nutrition and Genomics Laboratory, Tufts University
HUGH A. SAMPSON, Kurt Hirschhorn Professor of Pediatrics, Icahn School of Medicine at Mount Sinai
SCOTT H. SICHERER, Elliot and Roslyn Jaffe Professor of Pediatrics, Allergy and Immunology, Icahn School of Medicine at Mount Sinai
ANNA MARIA SIEGA-RIZ, Professor, Departments of Public Health Sciences and Obstetrics and Gynecology, University of Virginia School of Medicine
STEPHEN L. TAYLOR, Co-Director, Food Allergy Research and Resource Program, University of Nebraska–Lincoln
XIAOBIN WANG, Zanvyl Krieger Professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health
MARIA ORIA, Study Director
ALICE VOROSMARTI, Research Associate
ANNA BURY, Research Assistant (through April 2016)
KYRA CAPPELUCCI, Senior Program Assistant (through March 2016)
NOA NIR, Senior Program Assistant (from March 2016)
ANN YAKTINE, Board Director, Food and Nutrition Board
KIMBER BOGARD, Board Director (through July 2015), Board on Children, Youth, and Families
ANNE RODGERS, Science Writer
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
David B. Allison, University of Alabama at Birmingham
Dianne E Campbell, The University of Sydney
Rene W. R. Crevel, Unilever
Ruchi S. Gupta, Ann & Robert H. Lurie Children’s Hospital of Chicago
Peter Barton Hutt, Covington & Burling LLP
Robert P. Kelch, University of Michigan
Anita Kozyrskyj, University of Alberta
Richard M. Lerner, Tufts University
Rachel L. Miller, Columbia University Medical Center
Kevin Sauer, Kansas State University
Patrick Stover, Cornell University
Carina Venter, Cincinnati Children’s Hospital
Robert Wood, The Johns Hopkins Hospital
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Robert S. Lawrence, Johns Hopkins Bloomberg School of Public Health, and Huda Akil, University of Michigan. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
As pediatricians in training, we learned about life-threatening anaphylaxis and that prompt, appropriate treatment with a simple drug, epinephrine, saves lives. We mostly worried about anaphylaxis triggered by an undiagnosed drug allergy, or maybe by multiple bee stings. Food allergy was not well appreciated and was confused in our minds and those of parents with food intolerance, food sensitivity, and family reports of food reactions. Prevention of severe allergic reactions from peanut exposure in schools and airplanes was not discussed.
Food allergy is a complicated, multifactorial disease whose causes, mechanisms, and effects are not yet fully understood. The evidence on the true prevalence of food allergy is obscured by insufficient or inconsistent data and variable methodology. Despite these obstacles, public concern has grown in response to the apparent rising global prevalence of food allergies, and many health care experts who provide care to patients agree that any real increase in food allergies that has occurred is unlikely to be due simply to an increase in awareness. Numerous stakeholders are concerned about this rise in food allergies, including the general public, policy makers, regulatory agencies, the food industry, scientists, clinicians, and especially families of children and young people suffering from food-related allergies.
This consensus study is the result of a planning meeting that was held by the National Academies of Sciences, Engineering, and Medicine in response to broad public interest in the health aspects of food allergy, the relevance to public health, health care, and society, and the current lack of solutions both for preventing and managing food allergies. The goal of this consensus study is to review the science and management practices of food
allergies. Our committee intends that this report will clarify the nature of the disease, its causes, and its current management; highlight gaps in knowledge; encourage the implementation of food allergy management tools at many levels and among many stakeholders; and delineate a roadmap to safety for those who have, or are at risk of developing, food allergies, as well as for others in society who are responsible for public health.
This committee had the unique opportunity to hear directly from an advisory panel made up of nine parents of children with food allergies and one individual with food allergy. Members of the advisory panel were invaluable to the committee as meaningful examples of the sentiments and struggles of living with food allergies. We heard about the anxiety they feel in restaurants, schools, airplanes, and other settings where they are fearful about unintentional exposure to a food that can cause a life-threatening allergic reaction. The advisory panel asked for clear and consistent guidelines for diagnosing and managing food allergies and for treating reactions. We also heard their desire for more clarity in food labeling, appropriate training for emergency personnel, and greater access to epinephrine. And we heard their plea for a roadmap to safety so that people with food allergy and their family and friends can participate fully in the world without the fear of a severe or fatal food allergy reaction.
Drawing on insights from the advisory panel, as well as expert testimony, comprehensive literature reviews, committee expertise and deliberations, the committee recognized that preventing and treating food allergy and creating a roadmap to safety is a multifaceted undertaking that must take into account many interacting systems that influence both risks and safety over the life course. To address this, the committee decided that this report would benefit from taking an ecological and developmental perspective. This ecological-developmental model emphasizes the importance of developmental timing for food allergy exposures and for safety planning. The committee used this approach to delineate the issues, organize the evidence, draw conclusions, make recommendations, and communicate conclusions. The committee recognized that many sectors at multiple levels of organization in private and public life must be considered to understand and protect the individuals from the risks posed by food allergies.
The current paradigm of prevention and treatment is changing. As this report was being written, new evidence on the potential benefits of early introduction of allergens was emerging to dismantle previous views about the benefits of delaying introduction of allergens until 1 year of age or even later. These new studies are causing leading organizations to rethink the current recommendations and consider promising new prevention approaches. Understandably, these changes can lead to confusion among those at risk of food allergy and even among health care providers.
Thoughtful policies at many different levels, including guidelines and
regulations, can help protect public health. Although many nongovernmental organizations and governments provide tools, guidelines, and policies to promote greater safety in various settings (e.g., food industry practices, regulatory agencies, child care settings, schools, higher education, and public transport), their implementation and enforcement varies greatly across the United States. Moreover, policies and guidelines may not be keeping pace with the science.
This report is meant to be a review of scientific questions. In addition, this report reviews some of the management approaches that are in place to improve health and quality of life for individuals with food allergy and their caregivers. Finally, the committee envisions that this report will serve as a tool for all the stakeholders and the public to recognize the importance of this disease as well as to join forces in efforts to improve markedly our ability to understand, effectively manage, and ultimately cure food allergy, and to make the world safer for those afflicted with this disease.
The committee responsible for the report is varied in expertise, with members chosen for their experience in allergic diseases, immunology, pediatric medicine, epidemiology, genetics, epigenetics, public health, nutrition, food science, and the food industry. The chapters are authored jointly by committee members, who contributed their expertise to appropriate areas, subject to review and comment from the entire committee. Committee members volunteered countless hours to long but productive days of meetings in Washington, DC, and to research, deliberations, and preparation of the report. Many other people contributed significant time and effort to support the preparation of the report during open committee sessions and through presentations at a workshop. We are grateful for their efforts.
The committee could not have done its work without the initiative and collaboration from the Board on Children, Youth, and Families and superb guidance and support provided by the Food and Nutrition Board staff: Maria Oria, Study Director; Alice Vorosmarti, Research Associate; Anna Bury, Research Assistant; and Kyra Cappelucci and Noa Nir, Senior Program Assistants. The committee also benefited from the overall guidance of Ann Yaktine, Director of the Food and Nutrition Board. The committee is also especially thankful to Anne Rodgers, who edited this report.
Lastly, as chair, I express my sincere appreciation to each member of this committee and staff for their extraordinary commitment to the project and to the wonderful opportunity to work with them on this important task to improve the health and future of people around the world with food allergy.
Virginia Stallings, Chair
Committee on Food Allergies:
Global Burden, Causes, Treatment, Prevention, and Public Policy