Risk Management for Food Allergy

Risk Management for Food Allergy

Edited by

Charlotte Bernhard Madsen

DVM Research Leader Division of Toxicology and Risk Assessment National Food Institute Technical University of Denmark

René W.R. Crevel

Safety and Environmental Assurance Center, Unilever, Sharnbrook, Bedfordshire, UK

Clare Mills

Manchester Institute of Biotechnology, University of Manchester, UK

Steven L. Taylor

Food Allergy Research & Resource Program, University of Nebraska, Lincoln, NE, US

Table of Contents

Cover image

Title page

Food Science and Technology International Series

Copyright

List of Contributors

Foreword

Introduction

History of ‘Allergy’ Labeling

Where are we now – The Book

The Authors

Section 1: Food Allergy: Causes, Prevalence, and Impacts

Chapter one. Living with Food Allergy: Cause for Concern

Abstract

Introduction

Qualitative Studies on the Impact of Food Allergy on HRQL

Children and Teens: The Evolution of Uncertainty

The Parental Perspective: Living with Uncertainty

The Parental Perspective: Quantitative

The Child, Adolescent, and Adult Perspective: Quantitative

Discussion

Improving Risk Management and HRQL: A Better Way?

References

Chapter two. Which Foods Cause Food Allergy and How Is Food Allergy Treated?

Abstract

Introduction

Foods Involved in Allergic Reactions

Symptoms and Severity of Food Allergy

Management

References

Chapter three. The Epidemiology of Food Allergy

Abstract

Prevalence

Time Trends of Food Allergy Prevalence and Health Care Utilization

Risk Factors for Food Allergy

The Natural History of Food Allergies

The Consequences of Food Allergy

Conclusions

References

Section 2: Allergen Thresholds and Risk Assessment

Chapter four. How to Determine Thresholds Clinically

Abstract

Introduction and Definitions

Meal, Source Material, and the Matrix Issue

Factors Affecting the Outcome of Challenges

Inclusion and Exclusion Criteria for Patients to Undergo Titrated Challenges

Safety Aspects of Titrated DBPCFC

Pre- and Post-Challenge Assessments of Patients

Which Symptom Defines the Individual Threshold Dose?

Challenge Protocols and Dosing

An Open Food Challenge Always Has to Follow a Negative DBPCFC

References

Chapter five. Thresholds or ‘How Much Is Too Much?’

Abstract

Introduction

What is Meant by Thresholds in the Context of Food Allergy and Allergens?

Thresholds Before EuroPrevall: What Data Were Available and How Useful Were They for Risk Assessment?

How Have Threshold Data Been Generated? Protocols and Their Evolution

Factors Affecting the Outcome of Challenge Studies and the Type of Data Generated

Tools for the Analysis of Threshold Data

Conclusions

References

Chapter six. From Hazard to Risk – Assessing the Risk

Abstract

Introduction

Why and When is it Necessary to Estimate the Risk from Allergenic Food?

Safety Assessment in Food Allergy Using One Data Point (NOAEL or LOAEL) and an Estimated Food Consumption

Safety Assessment in Food Allergy Based on All Available Challenge Data and an Estimated Intake Food Consumption (Benchmark Dose/Margin of Exposure Approach)

Exposure Assessment

Risk Assessment in Food Allergy Based on the Distribution of Input Data (Challenge, Contamination, Consumption) (Probabilistic Approach)

Examples of Risk Assessments Using All Three Approaches

Summary of Risk Assessment Examples

Uncertainty Factors

Severity Considerations in Risk Assessment

VITAL Program

Concluding Remarks

References

Section 3: Risk Management of Gluten

Chapter seven. Celiac Disease and Risk Management of Gluten

Abstract

Abbreviations

Introduction

Definition of Celiac Disease

Gluten Sensitivity

Wheat (Food) Allergy

Diagnosis of Celiac Disease

A Public Health Problem

Time, Place, and Person

Clinical Presentation

Associated Diseases

A Multifactorial Etiology

Etiopathogenetic Considerations

Case Identification

Living with Celiac Disease

Risk Assessment in Celiac Disease

Adherence Problems

How to Keep Celiac Customers Happy and Safe?

Support Strategies

Perspectives for the Future

Case Stories

References

Section 4: Practical Food Allergen Risk Management

Chapter eight. Food Allergen Risk Management in the Factory – From Ingredients to Products

Abstract

Introduction

Allergen Risk Management: Principles and Systems

Employee Training and Awareness

Ingredients/Raw Materials – Suppliers, Storage, and Handling

Production – Material Flow, Factory and Equipment Design, Product Scheduling, and Rework

Production – Cleaning and Cleaning Validation

Labeling

References

Chapter nine. Managing Food Allergens: Case Histories and How They Were Handled

Abstract

Introduction

Case Study 1 – Supply Chain

Case Study 2 – Supply Chain, Manufacturing – ‘All Nuts are Equal’

Case Study 3 – Labeling

Case Study 4 – Manufacturing (Large Company)

Case Study 5 – Manufacturing (Rework)

Case Study 6 – Manufacturing and Design – ‘Nut Snow’

Case Study 7 – Manufacturing (Small Company)

Case Study 8 – Allergen Awareness – ‘No Protein = No Food Allergen: True or False?’

Case Study 9 – Product Development, Training, Allergen Awareness: – ‘Food Allergens: Never Heard of Them!’

Case Study 10 – Training, Allergen Awareness, and Supplier Verification

Case Study 11 – Auditor’s Allergen Awareness and Understanding

Case Study 12 – An Ethical Dilemma

Conclusion

References

Chapter ten. Catering – How to Keep Allergic Consumers Happy and Safe

Abstract

Introduction

Why Do Consumers Currently Not Have the Information They Need to Make Safe Choices When Eating Out?

What Is the Current Legal Position and Are Any Changes Expected?

Best Practice Guidance Published by the UK Food Standards Agency in 2008 on the Provision of Allergen Information for Non-Pre-Packed Foods

The Responsibilities of the Food Allergic Consumer

Future Developments and Recommendations

References

Chapter eleven. Food Allergen Risk Management in the United States and Canada

Abstract

Introduction

US National Food Allergen Risk Management

US State and Local Allergen Risk Management

Canadian National Allergen Risk Management

Conclusions

Chapter twelve. The Importance of Food Allergy Training for Environmental Health Service Professionals

Abstract

Introduction

The Effectiveness of an Avoidance Diet

Legislative Basis for the Risk Management of Food Allergens

The Role of the EHO in the Risk Management of Food Allergens

Deficits in Training Resources for Catering Staff

Deficits in Food Allergy Awareness Among Catering Staff

A Food Allergy Training Program for the Island of Ireland

References

Chapter thirteen. Detecting and Measuring Allergens in Food

Abstract

Introduction

Immunochemical Methods for the Detection of Food Allergens

Mass Spectrometry

Polymerase Chain Reaction (PCR)

Conclusions

References

Chapter fourteen. Effect of Processing on the Allergenicity of Foods

Abstract

Introduction

Effects of Processing Major Allergenic Foods of Plant Origin

Whole Food Effects of Food Processing

Conclusions

References

Chapter fifteen. Communication with Food Allergic Consumers: A Win-Win Experience

Abstract

Introduction

Start with the Basic Fact That Education and Sensitivity Training Related to Food Allergic Consumers Must Be Holistic and Inclusive

Putting the Program into Practice and Selling the Benefits Beyond Your Company

Conclusion and Summary

References

Chapter sixteen. May Contain – To Use or Not?

Abstract

Introduction

History and Origins of Precautionary Labeling

Legal and Regulatory Status of Precautionary Allergen Labeling

How to Determine the Tolerable Level of Risk

VITAL and a Threshold-Based Approach to Risk Assessment

The Future of Precautionary Statements

References

Chapter seventeen. Regulatory Controls for Food Allergens

Abstract

Introduction

How Best to Protect the Public at Risk from Adverse Reactions to the Major Food Allergens?

Why Do We Need Specific Allergen Labeling Rules?

Codex

European Legislation Regarding Food Allergen Risk Communication

‘Gluten-Free’ and Other ‘Free from’ Claims

Regulatory Lists Around the World

What is not Covered by Legislation?

Conclusions

References

Chapter eighteen. Keeping Updated

Abstract

Introduction

The Allergen Bureau (Australia)

The American Academy of Allergy, Asthma, and Immunology

Canadian Food Inspection Agency

Catering for Allergy (UK)

The European Academy of Allergy and Clinical Immunology

The European Food Safety Authority

Food Allergy Information (EU)

The Food Allergy Research and Resource Program (US)

Food Allergy Support (UK)

Food and Drug Administration (US)

The Food Standards Agency (UK)

The InformAll Database (UK)

Food Science and Technology International Series

Index

Food Science and Technology International Series

Series Editor

Steve L. Taylor, University of Nebraska – Lincoln, USA

Advisory Board

Ken Buckle, The University of New South Wales, Australia

Mary Ellen Camire, University of Maine, USA

Roger Clemens, University of Southern California, USA

Hildegarde Heymann, University of California – Davis, USA

Robert Hutkins, University of Nebraska – Lincoln, USA

Ron S. Jackson, Quebec, Canada

Huub Lelieveld, Bilthoven, The Netherlands

Daryl B. Lund, University of Wisconsin, USA

Connie Weaver, Purdue University, USA

Ron Wrolstad, Oregon State University, USA

A complete list of books in this series appears at the end of this volume.

Copyright

Academic Press is an imprint of Elsevier

The Boulevard, Langford Lane, Kidlington, Oxford, OX5 1GB, UK

225 Wyman Street, Waltham, MA 02451, USA

First published 2014

Copyright © 2014 Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangement with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

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A catalogue record for this book is available from the Library of Congress

ISBN: 978-0-12-381988-8

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List of Contributors

Anton Alldrick,     Campden BRI, Chipping Campden, UK

Ricardo Asero,     Ambulatorio di Allergologia, Clinica San Carlo, Paderno-Dugnano, Milano, Italy

Barbara K. Ballmer-Weber,     Allergy Unit, Department of Dermatology, University Hospital Zürich, Switzerland

Susan A. Baranowsky,     Consumer Affairs, Campbell Soup Company, Camden, NJ, US

Joseph L. Baumert,     Department of Food Science & Technology and Food Allergy Research & Resource Program, University of Nebraska, Lincoln, NE, US

Erna Botjes,     Stichting Voedselallergie (Dutch Food Allergy), Nijkerk, The Netherlands

Peter Burney,     National Heart Lung Institute, Imperial College, London, UK

Stella Cochrane,     Unilever Safety and Environmental Assurance Center, Sharnbrook, Bedfordshire, UK

René W.R. Crevel,     Safety and Environmental Assurance Center, Unilever, Sharnbrook, Bedfordshire, UK

Ross Critenden,     Valio Ltd, Helsinki, Finland

Anthony E.J. Dubois,     Department of Paediatric Pulmonology and Paediatric Allergy, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

George E. Dunaif,     Food Safety & Technical Services, Grocery Manufacturers Association, Washington, DC, US

Audrey DunnGalvin,     Department of Paediatrics and Child Health, University College Cork, Cork, Ireland

Montserrat Fernández-Rivas,     Allergy Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain

B.M.J. Flokstra-de Blok,     Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

Steven M. Gendel,     Food and Drug Administration, Center for Food Safety and Applied Nutrition, US

Linus Grabenhenrich,     Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Center, Berlin, Germany

Kirsten Grinter,     Nestle Oceania, Rhodes, NSW, Australia

Sue Hattersley,     Food Standards Agency, London, UK

Geert Houben,     Food & Nutrition, TNO, Zeist, The Netherlands

Steffen Husby,     Hans Christian Andersen Children’s Hospital at Odense University Hospital, Denmark

Anneli Ivarsson,     Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden

Phil E. Johnson,     Institute of Inflammation and Repair, Manchester Academic Health Science Center, Manchester Institute of Biotechnology, University of Manchester, Manchester, UK

Thomas Keil,     Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Center, Berlin, Germany

Rita King,     British Beer and Pub Association, London, UK

André C. Knulst,     Department of Dermatology/Allergology, University Medical Center, Utrecht, The Netherlands

I.S. Leitch,     Environmental Health Department, Omagh District Council, Omagh, Co. Tyrone, Northern Ireland

Charlotte Bernhard Madsen,     DVM Research Leader Division of Toxicology and Risk Assessment National Food Institute Technical University of Denmark

J. McIntosh,     Safefood, Eastgate, Little Island, Co. Cork, Ireland

Clare Mills,     Institute of Inflammation and Repair, Manchester Academic Health Science Centre, Manchester Institute of Biotechnology, University of Manchester, UK

Pia Nørhede,     Division of Toxicology and Risk Assessment, National Food Institute, Technical University of Denmark, Lyngby, Denmark

Jonathan O’B. Hourihane,     Department of Paediatrics and Child Health, Clinical Investigations Unit, Cork University Hospital, Wilton, Cork, Ireland

Cecilia Olsson,     Department of Food and Nutrition, Umeå University, Sweden

Sylvia Pfaff,     Food Information Service (FIS) Europe, Bad Bentheim, Germany

David Reading,     Food Allergy Support Ltd, Aldershot, UK

Ben C. Remington,     Department of Food Science & Technology and Food Allergy Research & Resource Program, University of Nebraska, Lincoln, NE, US

Robin Sherlock,     FACTA, Tennyson, Queensland, Australia

Dan Skrypec,     Kraft Foods, Glenview, IL, US

Steven L. Taylor,     Food Allergy Research & Resource Program, University of Nebraska, Lincoln, NE, US

Marjan van Ravenhorst,     Allergenen Consultancy, Scherpenzeel, The Netherlands

Jean-Michel Wal,     INRA, Unité d’Immuno-Allergie Alimentaire, Jouy-en-Josas, France

Rachel Ward,     r.ward Consultancy Limited, Nottingham, UK

Gary Wong,     Department of Paediatrics, Chinese University of Hong Kong, New Territories, Hong Kong, China

Laurian Zuidmeer-Jongejan,     Department of Experimental Immunology, Laboratory of Allergy Research, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

Foreword

I first became aware of food allergen issues in the late 1990s when I was Director of the Center for Food Safety and Applied Nutrition (CFSAN) at the US Food and Drug Administration (FDA). The agency had contracted with two states to survey local food manufacturing plants that made food products (such as cookies), some of which were intended to contain, and some of which were intended not to contain, common food allergens such as milk and eggs. The states collected samples of the products not intended to contain food allergens and tested them to verify this. The results were astounding, as an alarming percentage of products actually contained milk or eggs when they were not supposed to.

This survey caught everyone's attention. It helped explain two things: (1) why undeclared food allergens were the number one cause of Class 1 recalls (those recalls presenting the most serious risk to health) and (2) why the government and the food industry needed to do much more to reduce the likelihood of this from happening. After all, a clear and dependable food label is the only means that food allergic individuals (and parents of food allergic children) have to prevent illness and injury. Accurate food labels are truly their lifeline.

In the ensuing 10+ years, much has been done to advance the awareness of food allergen issues and to put in place systems to better protect food allergic individuals.

• US Congress passed the Food Allergen Labeling and Consumer Protection Act (FALCPA) of 2004, which required the prominent listing – in plain English – of the eight most common food allergens: peanuts, tree nuts, milk, eggs, fish, shellfish, soy, and wheat. Today, food allergic consumers (and their parents) have a much easier time determining which foods are safe for them to eat.

• The US National Institutes for Health (NIH) have significantly increased the amount of funding devoted to studying potential cures for food allergies, thereby recognizing that food allergies are a significant health issue that needs to be addressed.

• There is much greater public awareness that a food allergic individual can be placed in a life-threatening situation if the wrong food allergen is consumed. This awareness has led to greater vigilance in public schools and the passage of state laws directing that ambulances carry the drug epinephrine – which is needed almost immediately for emergency treatment.

• Most recently, in late 2010, US Congress passed sweeping food safety legislation – called the US FDA Food Safety Modernization Act (FSMA) – which included a clear mandate for greater control of food allergens during the food manufacturing process.

Such progress does not happen by accident. The hard work of many, many people and organizations has been brought to bear. Three stand out for special mention.

• First was the creation of the Food Allergy and Anaphylaxis Network (FAAN) over 20 years ago by two parents of a food allergic child, Anne Munoz-Furlong and Terry Furlong. Having nowhere to turn for reliable information, they decided to research the issue themselves and become a clearing-house for objective, scientific information to share with other parents like themselves. The organization grew into a membership of over 30,000, and FAAN became the world leader in food allergy education. I had the honor to serve on the FAAN Board of Directors for six years (serving as Chair for one year) and can attest to the values and dedication this group has brought to bear. More recently, FAAN merged with the Food Allergy Institute (FAI) group, with great success in raising money for clinical research to form the consolidated group called Food Allergy Research and Education (FARE).

• Second was the establishment of a clinical research program at Mt. Sinai hospital in New York. Headed by Hugh Sampson, M.D., this facility has become the national leader in food allergy clinical research. It has close ties to FARE and both of its predecessor organizations. It is hoped that more research programs will arise around the country to add to our base of expertise, and the increased number of US National Institute of Health grants referenced above should facilitate reaching this goal.

• Third is a group at the University of Nebraska, headed by Stephen L. Taylor, Ph.D., called the Food Allergy Research and Resource Program (FARRP). This group is the national leader in understanding how to detect and measure food allergens in food and in assessing the risk to health, if any, of tiny amounts of food allergens. It is hoped that research of this type will help establish ‘thresholds’ for food allergens – meaning, safe levels that food companies can test against.

Despite such progress, many challenges remain. Awareness of the food allergy issues needs to be maintained and even enhanced, education of new parents with food allergic children is a continuing necessity, advocacy for stronger laws continues, and research needs to be continued until a cure is found.

What I have learned most over the past decade is that with food allergies, there are no villains – only victims – but also many champions trying to protect them. Thankfully, the number of champions is constantly growing. Those contributing to this book are high among them and deserve our collective admiration and gratitude.

Joseph A. Levitt¹

¹Mr. Levitt is a partner in the Washington, D.C., office of Hogan Lovells US LLP, where he counsels food companies on, among other matters, food allergen-related issues. He is the former Director of FDA’s Center for Food Safety and Applied Nutrition (CFSAN). He is also a former Board Member and Chair of the Food Allergy and Anaphylaxis Network (FAAN).

Introduction

You can’t have no risk at all you know, even if the child never leaves the house, so you have to deal with risk ... we just want a better way

(Mother of Carla, aged 10, US).

like sometimes you can’t find the cause [of a reaction] … it just happens, you know … not knowing makes you worried and unsure of yourself … when I have a first bite like, if I’m not at home, I think is this it? ... will I die? ... what can you do?

(Fran, aged 12, Ireland)

These statements from chapter 1 describe the reality of living with severe food allergy.

Managing food allergy on an individual level is the responsibility of the individual and those looking after that individual. In the modern world this is very, very difficult without help from society.

Food is an essential part of our lives. We eat approximately five times a day, very often away from home. Food allergic individuals have to rely on the information about the food they eat from the persons producing their food. They have to trust that food producers, both in industry and catering, know how crucial it is that the information they provide is correct. This means that, although the individual has to manage his or her food allergy, the food producers need to manage allergenic foods.

Food producers need to manage many different risks. This is costly, and an important driving force in prioritizing has been legal and regulatory requirements.

History of ‘Allergy’ Labeling

In the eighties, international food labeling was extremely focused on food additives. This resulted in labeling rules where ingredients such as milk or wheat did not have to be declared on the label if they were constituents of compound ingredients (the so-called 25% rule), whereas food additives always had to be labeled. This rule could result in ingredient lists dominated by additives and made it almost impossible for food allergic individuals to get appropriate information from ingredient lists.

In order to change international food labeling rules to make them more helpful to food allergic individuals, a Nordic initiative led by Norway in 1993 presented a document (Consideration of Potential Allergens in Food) to the Codex Committee on Food Labeling. The documents suggested changing the 25% rule on compound ingredients to a 5% rule and suggested a list of allergenic foods that should always be declared. The matter was discussed again in 1994 and 1995, and in November 1995 a FAO Technical Consultation on Food Allergens was held. The recommendations from this consultation were to change the 25% rule as suggested. The suggested list of allergenic foods was slightly modified. After several years of further discussion the Codex Alimentarius Commission adopted the proposal in June 1999.

Several countries changed their food labeling rules in accordance with the Codex. In the EU the 25% rule was totally abandoned in 2004.

The change in labeling rules and the increased focus on allergenic foods has been an advantage for the allergic consumer, but it also created unforeseen problems. These arise from insufficient scientific knowledge on safe levels of food allergens. The European Food Safety Authority concluded in 2004 that:

The doses of allergens capable of triggering food allergic reactions are variable and can be very small, i.e., in the milligram or microgram range. The information currently available is insufficient to draw firm conclusions regarding the lowest dose that could cause an adverse effect (threshold).

For this reason, the authorities were not able to advise industry on what amounts of food allergen could be considered effectively harmless and help them to develop operational standards.

This again led industry to develop various labels such as ‘may contain nuts’ or ‘manufactured in a facility that also handles nuts’, because they were not able to guarantee the total absence of allergenic food in their products and no one could tell them when their products were safe enough. A further consequence of the lack of guidance was that criteria for using such labeling varied across the food industry.

Where are we now – The Book

Unfortunately we have not solved all the questions that arise when dealing with allergenic food in food production, but much has happened. This book presents the newest knowledge on food allergy and food allergen management and includes suggestions for practical management of food allergens.

The book is organized in four sections. Section 1, Food Allergy: Causes, Prevalence, and Impacts, provides a background for understanding the context and rationale for food allergy as a problem in society. It gives an overview of how patients experience daily life with food allergy and how it impacts their lives. It describes food allergy as a disease and lists which foods cause allergy as well as the epidemiology of food allergy. Section 2, Allergen Thresholds and Risk Assessment, describes how clinicians determine the amount of allergenic food causing a reaction. It suggests quantities of different allergenic foods that can be considered to present minimal risk and describes how they are derived and how these data are used in risk assessment, both theoretical and in practice. Section 3, Risk Management of Gluten, gives an overview of the gluten-induced disease celiac disease with emphasis on diagnosis, prevalence, prevention, and management. Section 4, Practical Food Allergen Risk Management, focuses on the practical aspects, including how allergenic food is managed in a factory and in catering businesses. It has stories illustrating how concrete problems with food allergens in production were handled and explains the role of health service professionals. It describes the analytical detection methods for food allergens and the ways that processing can alter the allergenicity of foods. It covers effective communication with consumers including the use of ‘may contain’ labeling. Lastly it gives a short overview of legislation and useful places to keep updated.

The Authors

The authors are clinicians, researchers, and public and industrial risk assessors and risk managers. Many of the authors have been partners of the EU-funded research project The Prevalence, Cost and Basis of Food Allergy in Europe (EuroPrevall) and present data from the project.

Charlotte Bernhard Madsen, René W.R. Crevel, Clare Mills and Steven L. Taylor

Section 1

Food Allergy: Causes, Prevalence, and Impacts

Outline

Chapter one Living with Food Allergy

Chapter two Which Foods Cause Food Allergy and How Is Food Allergy Treated?

Chapter three The Epidemiology of Food Allergy

Chapter one

Living with Food Allergy

Cause for Concern

Audrey DunnGalvin¹, Anthony E.J. Dubois², B.M.J. Flokstra-de Blok³ and Jonathan O’B. Hourihane⁴,    ¹Department of Paediatrics and Child Health, University College Cork, Cork, Ireland,    ²Department of Paediatric Pulmonology and Paediatric Allergy, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands,    ³Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands,    ⁴Department of Paediatrics and Child Health, Clinical Investigations Unit, Cork University Hospital, Wilton, Cork, Ireland

Abstract

Although a growing number of families must live and cope with food allergy on a day to day basis, it is only in recent years that the socio-emotional impact of food allergy on children, teens, adults, and parents has been researched in depth. The EuroPrevall project (europrevall@bbsrc.ac.uk) gave great impetus to research in this area. In addition to clinical research on the prevalence, mechanisms, and causes of food allergy, research output in the area of psychosocial impact included health-related quality of life (HRQL) measures for all age groups and examination of the socio-economic impact of food allergy.

Qualitative studies were also carried out under EuroPrevall to provide an in-depth picture of the impact of food allergy on everyday life, and the type of experiences and coping strategies that evolve in response a diagnosis of food allergy. Involving children and teens, as well as adults and parents, in research is important, because children are increasingly acknowledged to have rights in the determination of medical decisions that affect them. In addition, a greater understanding of children and young peoples’ views on the impact of a disease on their experiences and relationships allows us, as health professionals, to respond more appropriately.

In this chapter, research from Europe, Asia, Australia, and the US will be brought together, and discussed, in terms of EuroPrevall and Cork Research Group findings on the impact of food allergy on the everyday lives of parents, infants, children, teens, and adults. Topics will include food anxiety, social and dietary restrictions, general emotional impact, auto-injector use/non-use, labeling, and coping strategies. We conclude by highlighting key concerns and making suggestions for future research and practice based on our findings.

Keywords

food allergy; EuroPrevall; prevalence; mechanism; cause; psych-osocial impact; food anxiety; social restriction; dietary restriction

Chapter Outline

Introduction

Qualitative Studies on the Impact of Food Allergy on HRQL

Children and Teens: The Evolution of Uncertainty

The Parental Perspective: Living with Uncertainty

The Parental Perspective: Quantitative

The Child, Adolescent, and Adult Perspective: Quantitative

Discussion

Improving Risk Management and HRQL: A Better Way?

References

Introduction

Since, at present, there is no ‘cure’ for food allergy, avoidance of the responsible allergenic food and emergency management in the form of injectable epinephrine (EpiPen or Anapen), in case a food allergen is accidentally ingested, is the only reliable therapy offered to those living with such conditions. However, ‘avoidance’ is not as straightforward as it might first appear. Firstly, it is complicated by the fact that foods like peanuts, nuts, or soy can be found in many foods (e.g., breads, muffins, pastries, biscuits, cereals, soups, ice creams, seasoning, sauces) and in different forms. Living with a food allergy also means constantly reading food ingredient labels, concern for cross-contamination, vigilance in a variety of social activities, and immediate access to an auto-injector [1]. Secondly, symptoms may occur within minutes of ingesting a food allergen, include itching and swelling of the lips, tongue, and soft palate as well as nausea, abdominal pain, vomiting, and diarrhea. Anaphylaxis refers to a sudden, severe, potentially fatal, systemic allergic reaction that can involve the skin, respiratory tract, gastrointestinal tract, and cardiovascular system. The most dangerous symptoms include breathing difficulties and a drop in blood pressure, or shock, which are potentially fatal. Therefore, although the life-threatening nature of anaphylaxis makes prevention the cornerstone of therapy, it also has implications for the health-related quality of life of the children, teens, and adults living with the allergy.

In the past, the medical community defined health as an absence of disease. It is now recognized that health consists of physical, psychological, and social aspects. Because the concept of health has changed, the way we measure health or the impact of any disease has also changed. Health professionals now know that it is essential to use outcome measures that reflect the patient’s perspective in order to gain a truly meaningful picture of the impact of a disease on a patient’s everyday life [2]. We call this health-related quality of life (HRQL). The perception of HRQL is influenced by the individuality and subjectivity of experience and response, and may depend on many factors, such as age, gender, context, and culture [3–7]. Therefore, physiological measures often relate poorly with perceived physical well-being [8], and patients with the same clinical criteria often have dramatically different responses. To give an example, two patients with the same prognosis following an operation for a heart bypass can have two very different perspectives on how their lives have changed. For one it may be an opportunity, for others it may be perceived as a catastrophic event that changes how they see themselves, how they interact with others, and how they perceive the overall quality of their everyday lives. In turn, this can impact on how well they follow medical advice for their future health. It has become increasingly important, therefore, for researchers and healthcare professionals to understand how the perceptions, experience, and impact of a chronic disease might influence a patient’s interpretation and response to it, so that we in turn can respond more appropriately. Furthermore, involving children as well as adults and parents in research is important, because children are now acknowledged to have rights in the determination of medical decisions that affect them [9]. This has encouraged research to be undertaken with children themselves to understand their views on the impact of a disease on their experiences and relationships.

Although a growing number of families must live and cope with food allergy on a day-to-day basis, it is only in recent years that the socio-emotional impact of food allergies on children, teens, adults, and parents has been researched in depth. The EuroPrevall project (europrevall@bbsrc.ac.uk) gave great impetus to research in the area of HRQL. In addition to clinical research on the prevalence, mechanisms, and causes of food allergy, research output in the area of psychosocial impact included HRQL measures for all age groups, and an examination of its socio-economic impact.

HRQL is measured by two major types of instruments; generic and disease-specific. Generic HRQL instruments are not specific to any particular disease and are therefore useful for comparing HRQL across different conditions, whereas disease-specific questionnaires focus on issues pertinent to one disease. However, generic instruments are necessarily more ‘general’ and therefore less sensitive to the particular problems associated with a particular condition [9]. For example, asking parents of children with food allergy if their disease impacts on their children’s ability to run up and down stairs will provide meaningless results. In contrast, asking the same parents if children feel left out at birthday parties because of their food allergy provides a picture of its impact on the children’s ability to take part fully in everyday social events – activities that children without food allergy enjoy without much thought or restriction. Disease-specific HRQL questionnaires provide an in-depth picture of the day-to-day concerns of patients and are also able to capture small changes in HRQL that may occur as a result of clinical or therapeutic treatment.

Several disease-specific measures have been developed under the aegis of EuroPrevall to assess quality of life in children and teens. These include the Food Allergy Quality of Life Questionnaire – Parent Form (parent-administered for children aged 0–12 years); the Food Allergy Quality of Life Questionnaire – Child/Teen Form (self-administered for children and teens aged 8–17 years) and the Adult Form (for those aged 18+). These questionnaires were developed according to gold standard methodologies [10–15].

Health-related quality of life instruments capture the impact of food allergy; however, the manner in which it is experienced and managed every day (coping) must also be evaluated [1,3,7]. Coping has not only been shown to be related to patient HRQL, but is also strongly linked to health behavior [16], having both the short- and long-term impacts. To illustrate this, we return to our earlier example of the two patients with the same prognosis following heart bypass surgery. They may, for example, be unable to return to their previous employment because of their changed health circumstances. Whereas one may cope with this experience by viewing the surgery as an opportunity to change their lives, to become healthier, to experience new challenges, others could ‘give up,’ become depressed, reject the company of friends, and feel that they no longer have a meaningful contribution to make to society. Here we have the same prognosis, but very different coping strategies. Research tells us that children with any chronic condition have twice the risk of developing mental health disorders as do healthy children, even without an accompanying physical disability [17]. Therefore, efforts have increasingly been made to assess how well children and adolescents cope with chronic conditions. In the context of research in children, qualitative research also provides an opportunity to tap into the richness of children’s thoughts and feelings about themselves, their environments, and the world in which they live.

In this chapter, we will look at the impact of food allergy on HRQL and subsequent risk management. Firstly, we will let the children, teens, and families describe, in their own words, what it is like to live and cope with a food allergy every day. Qualitative studies were also carried out under EuroPrevall, both in the initial focus groups put in place to generate items for the questionnaires, and independently thereafter. The findings will be presented in the context of a developmental model that captures the pathway from childhood to adolescence and explains why some children are ‘anxious’ while others are ‘risky.’

We will then discuss some scientific research on HRQL, the majority generated over the life of the EuroPrevall project. Research on factors (such as risk perception) that are related to, and impact on, HRQL are also examined. There is a strong emphasis throughout on developmental considerations in food allergies, from infants to adults. We conclude by offering some recommendations for future research and practice in food allergy risk management, based on the findings in this review.

Qualitative Studies on the Impact of Food Allergy on HRQL

Experience and coping in any chronic disease is an intricate pattern of ‘facts’ and ‘feelings’ interwoven into a child’s developmental pathway from birth to adulthood. Lay perceptions of risk may seem irrational to some clinicians, but have their own logic and validity from the perspective of those living and coping with food allergy. Here we use the patients’ and parents’ own voices to explore what it is like to live with food allergy, in order to better understand the decisions they make about managing their condition.

The findings will be framed within an integrated developmental framework [3] to explain the onset, development, and maintenance of food allergy–related cognitions, emotions, and behavior. In order to develop this framework we interviewed 120 children/teenagers aged 6–18 years in 15 age-appropriate focus groups. Fifty-two percent of the children were female. Parents were also interviewed. All children were physician diagnosed with IgE-mediated food allergy and had been issued an Anapen/EpiPen. Developmentally appropriate techniques such as vignettes or stories (where children could comment on characters in the third person) and activity books were designed to stimulate discussion, maintain interest, and minimize threats to the child’s self-esteem.

Analyses of the data encompassed precipitating events (stressful events in the children’s lives caused by food allergy–related factors); psychological impact (cognitive appraisal and emotional effects); and behavioral consequences or coping strategies. Our findings indicated that experience and coping in food allergy situations is complex and dynamic, comprising a series of interactive processes (both age-, gender-, and disease-specific) that are embedded in a child’s developmental path.

Subsequently, we also analyzed data from focus groups and interviews held in Australia (N=60), the UK (N=72), Italy (N=45), Singapore (N=20), and the US (N=45). The themes that emerged from other countries were strikingly similar to our previous research, including the impact of living with uncertainty, with difference, with rules and the coping strategies used (Figure 1.1). The findings [3–4,18–21] are discussed below using direct quotes from parents, children, teens, and young adults.

FIGURE 1.1 An illustration of the developmental model.

Because they were diagnosed when infants, young children feel that they are ‘the same’ as other children and parents help them to feel normal and protected in their everyday lives. They therefore have an illusory perception of control and certainty. As children become more aware of the rules as restrictive, together with a growing awareness of difference and uncertainty, the search for normality becomes stronger and children evolve strategies in order to cope. Although their roots may be discerned in children in the youngest age group, by adolescence, children's coping strategies become more defined, and in some cases more rigid, and an expanding social world gives further impetus to the search for normality. DunnGalvin and Hourihane JACI, 2009.

Children and Teens: The Evolution of Uncertainty

Because children are rapidly changing in response to physiological, social, and psychological influences, the developmental process plays an important role in shaping and determining their health and HQRL. Children’s social and emotional experiences are essential in shaping how the child will manage and live with their illness, both in the short and long term. Sensitive transition points occur along the developmental pathway when physiological (e.g., puberty) or environmental (school change) variables may have a significantly higher impact.

Middle childhood is when children begin to