Food Allergies Among Children - Growth, Treatment, Prevention and a Challenge for the Food Industry Steve L. Taylor, Ph.D. Food Allergy Research & Resource Program University of Nebraska Food Navigator USA Food for Kids! Summit Chicago IL November 13, 2018
Food Allergies The food of one may be poison for another. Lucretius De Rerum Natura 2
Food Allergies Abnormal response of human immune system Caused mostly by naturally-occurring proteins Immediate symptoms IgE antibodies against food allergens (proteins) Delayed symptoms inflammatory responses from immune cells against food allergens (proteins) Variable symptoms among affected individuals IgE-mediated Allergy Mechanism sensitization followed by elicitation (immediate onset) Cell-mediated Allergy Mechanism celiac disease (gluten-sensitive enteropathy) delayed onset 3
The Big 8 Most Common Causes of IgE-Mediated Food Allergy Milk Egg Crustacea Fish Peanut Soybean Tree nuts Wheat 4
Food Allergy Prevalence 10% Hundreds of others 90%- The Big 8 Peanut Soy Tree nuts Fish Milk Shellfish Egg Wheat There are 160+ other foods that can cause allergic reactions Hefle et al. 1996. Critical Reviews in Food Science and Nutrition 36:S69-S89 5
Some Quick Food Allergy Facts Up to 15 million U.S. consumers have food allergy The prevalence of food allergies is growing rapidly Reactions can occasionally be quite severe, even fatal The prevalence of severe reactions is also increasing rapidly Reactions happen immediately after ingestion Threshold dose for provoking a reaction is quite low Avoidance is the only strategy for reaction prevention Allergic consumers are diligent label readers 6
Food allergy affects between 2% and 8% of consumers Reactions are to specific food proteins: reactions are usually mild, but can be quite severe Angioedema Asthma Hives Eczema/dermatitis Vomiting Diarrhea Hypotension Mostly IgEmediated reactions but sometimes more complex RARELY Systemic Anaphylaxis, which can result in death 7
Age Group Distribution of Food Allergy Insurance Claims 8
Why Are Some Kids Allergic to Foods? Genetics Exposure to allergenic food Age at exposure Dose, frequency, and duration of exposure Immunogenicity of the food 9
Why Are Some Kids Not Allergic to Foods? Genetics Development of oral tolerance Exposure to allergenic food Age at exposure Dose, frequency, and duration of exposure If these are the key factors, then infant feeding and weaning practices must be important 10
Some Quick Food Allergy Facts Prevalence of food allergy in children has doubled over past 10 years Prevalence of peanut allergy has tripled in past 20 years An average of 2 food-allergic kids per elementary school classroom Severity of cases also seems to be increasing Percentage of children with multiple food allergies is increasing 11
Why Is the Prevalence of Food Allergies Increasing? What Are We Doing Differently? What Were Parents Doing Differently 30+ Years Ago When Food Allergy Prevalence Was 33% of What It Is Today? 12
Why is Prevalence Increasing? Multi-factorial Weaning practices Formula feeding vs. breast-feeding Cesarean sections Rural vs. urban hygiene hypothesis Vitamin D, sunlight, seasonal differences Improved diagnosis Variable access to quality health care Others 13
Can Food Allergies Be Prevented? For peanuts, the answer is a qualified YES LEAP Study Du Toit, G., et al., Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. New England Journal of Medicine, 2015. 372(9): p. 803-813. 14
LEAP Study Started with an observation that the prevalence of peanut allergy was high among Jewish infants (<5 yrs) in London compared to Jewish children in Tel Aviv (<5 yrs) Why? Du Toit, G., et al., Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. Journal of Allergy & Clinical Immunology, 2008. 122: p. 984-991. 15
LEAP Study Study of British infants at high risk of developing peanut allergy because they had existing egg allergy and severe eczema Would early feeding of peanut in form of Bamba lessen the likelihood of development of peanut allergy? Randomized 640 high-risk infants (4-11 months old) into two groups Randomly assigned to consume or avoid peanut until 5 years of age Du Toit, G., et al., Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. New England Journal of Medicine, 2015. 372(9): p. 803-813. 16
LEAP Results Du Toit, G., et al., Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. New England Journal of Medicine, 2015. 372(9): p. 803-813. 17
Questions Following LEAP Study Can the results of the LEAP Study with peanuts be extended to all other allergenic foods? Can the results of the LEAP Study be extended to other infants who are not high risk? How do we change the advice given to several generations of mothers? 18
Prevention of Food Allergies Innovation Opportunities The LEAP study was incredibly positive. Should weaning foods be made for infants to prevent allergies? For peanuts? For all foods? For high risk babies? For all babies? 19
Hello Peanut Inspired Start First Nuts Spoonful One 20
Some Quick Food Allergy Facts Up to 15 million U.S. consumers have food allergy The prevalence of food allergies is growing rapidly Reactions can occasionally be quite severe, even fatal The prevalence of severe reactions is also increasing rapidly Reactions happen immediately after ingestion Threshold dose for provoking a reaction is quite low Avoidance is the only strategy for reaction prevention Allergic consumers are diligent label readers 21
Teenager s Fatal In-Flight Reaction Raises Food Allergy Labeling Loophole Daddy, help me, I can't breathe : Family blames mislabeled food for death of 15- year-old with sesame allergy Boy, 3, Allergic to Dairy, Dies After Eating Grilled Cheese at Pre-K Tragic Spring: 3 Food Allergy- Related Deaths After 11-year-old boy's sudden death, mom warns about food allergies 22
Food Allergy Facts Food allergies result in 300,000+ ambulatory-care visits a year among children under the age of 18. Every 3 minutes a food allergy reaction sends someone to the emergency department approx. 200,000 visits PY A severe anaphylactic reaction occurs once every 6 minutes At least 9,500 hospital discharges per year with a diagnosis related to food allergy among children under age 18 years. Food allergy is the leading cause of anaphylaxis outside the hospital setting. Teenagers and young adults with food allergies are at the highest risk of fatal food-induced anaphylaxis. More than 15% of school aged children with food allergies have had a reaction in school. Number of fatal reactions is unknown but dozens to 100+ per year in USA 23
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Some Quick Food Allergy Facts Up to 15 million U.S. consumers have food allergy The prevalence of food allergies is growing rapidly Reactions can occasionally be quite severe, even fatal The prevalence of severe reactions is also increasing rapidly Reactions happen immediately after ingestion Threshold dose for provoking a reaction is quite low Avoidance is the only strategy for reaction prevention Allergic consumers are diligent label readers 25
How Much is Too Much? Milligram amounts! (ppm concentrations) 26
Peanut Allergic Patients Present with Different Levels of Sensitivity Ballmer-Weber and Hourihane 0.2 mg (0.05 mg) 0.4 mg (0.1 mg) 1.0 mg (0.25 mg) 5.0 mg (1.25 mg) 25 mg (6.25 mg) 100 mg (25 mg) 400 mg (100 mg peanut protein) *0.4 mg peanut (0.1 mg peanut protein) is the eliciting dose of the most sensitive peanut-allergic patient reported in the published clinical literature 27
Can Food Allergies Be Cured? Traditional Avoidance Diets Innovative - Immunotherapy 28
Can Food Allergies Be Cured? Traditional Avoidance Diets Innovative - Immunotherapy 29
How Consumers Manage a Food Allergy Avoid offending food Label education and diligent reading Brand loyalty = safety 30
Problems with Specific Avoidance Diets Exquisite sensitivity Degree of selectivity Knowledge of food composition Confusing labeling terms Adequate nutrition Restaurant meals 31
Food-Allergic Consumers: Quality of Life Time and energy required for vigilant avoidance diets Fear of severe or fatal reactions Anxiety, stress, social isolation Report significantly poorer general health than general public 32
Can Food Allergies Be Cured? Traditional Avoidance Diets Innovative - Immunotherapy 33
Can Food Allergies Be Cured with Immunotherapy? Sort of but not exactly Desensitization vs. Tolerance 34
Treatment Options Oral Immunotherapy (OIT) - Aimmune Uses peanut flour provided orally in gradually increasing doses Raises individual threshold from <100 mg peanut protein (<1/2 peanut) to 600+ mg (2 peanuts) over several months of OIT Then, must maintain with daily peanut intake of 600 mg peanut protein Epicutaneous Immunotherapy (Peanut Patch) DBV Uses peanut allergens on a patch that is affixed to the skin Raises individual threshold from <100 mg peanut protein (<1/2 peanut) to 300 mg (1 peanut) over several months Then, must maintain daily peanut intake of 300+ mg peanut protein Some patients do develop sustained unresponsiveness (tolerance) 35
Issues with Immunotherapy? Not a cure, only desensitization An increasing in personal threshold from low mg to 100s of mg relieves anxiety Time-consuming therapy Expensive; not yet covered by insurance Not yet widely available but coming soon Adverse reactions occur esp. with OIT Personal thresholds can vary with illness, exercise, menstruation, maybe alcohol, etc. Must stay on maintenance dose after IT complete 36
Maintenance Doses Vary from 500 mg up to 4000 mg peanuts (big Virginia peanuts weigh about 1000 mg) If you quit daily/weekly peanut ingestion, you are likely to slip back to being reactive to low doses Drug vs. food? Cost? Opportunity! 37
Summary Food allergies increasing but prevention strategies are emerging Cure does not exist but desensitization is possible and probably soon will become mainstream Accurate labeling remains be necessary The future is brighter but we still have a ways to go 38
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