"Everyone's Gone Nuts" -- A doctor responds to the Harper's Magazine article
This month's Harper's magazine features an article written by Meredith Broussard, called "Everyone's Gone Nuts: The Exaggerated Threat of Food Allergies."
Pretty inflammatory title to any of us with food allergies or the parent of a food allergic child.
She goes on to "dismantle" these myths, some of which rang true for me (fearful parents and children) and others that seemed patently wrong (exaggerated numbers of deaths from anaphylactic shock).
I turned to a friend and pediatric allergist Dr. Mike Pistiner to help me sort through fact and fiction.
(Note: Dr. Pistiner's answers include references to information on studies and journals he talks about. A list of these materials is available at the end of this SharePost.)
SLOANE MILLER: Ms. Broussard states that FAAN.org has exaggerated the threat of severe, life threatening food allergies and that they have based their number on one outdated study. Is this true?
DR. MICHAEL PISTINER: According to Broussard, the 150 to 200 deaths and 30,000 episodes of anaphylaxis in the United States each year were based on a 5-year study (1983 to 1987) by Yocum and colleagues in Olmsted County, Minnesota (a population that is similar in demographics to the white American population).
This study was published in the well respected Journal of Allergy and Clinical Immunology in 1999. (Yocum et al. JACI. 1999;104:452)
This was a groundbreaking study. Though it's 20 years old, the information continues to be useful and, for some statistical facts, unmatched. Its uniqueness and usefulness is that all of the medical records (clinic, hospital, ER, etc.) from all of the residents of this county were collected and reviewed, giving the author of the study and his colleagues the rare opportunity to identify even cases of anaphylaxis that were misdiagnosed, mislabeled and would have otherwise not been reported (Weiler. JACI. 1999; 104:271-3).
It is common that researchers and clinicians use the results of studies such as this one to estimate how many people in the nation's population as a whole suffer from a disease. Based on the 2007 population estimated numbers, one could predict that there would be 32,523 cases of food-induced anaphylaxis and 211 related deaths. FAAN and the many reputable investigators who derive numbers from this study are not misrepresenting or exaggerating the statistics, they are using the available data.
SM: Remember the now famous story of a peanut-allergic teen that supposedly died from kissing her boyfriend who had eaten peanuts? The coroner later proved that she died from an asthma attack. (Read the coroner's report.)
Can asthma be part of an allergic or anaphylactic reaction?
MP: Yes. Anaphylaxis can trigger asthma attacks that are notoriously difficult to treat. Wheezing, cough, chest tightness, and shortness of breath commonly occur during an asthma attack but are also life threatening symptoms seen during anaphylaxis (Wang. Clinical and Experimental Allergy, 37, 651-660). In some cases, respiratory symptoms can be the only manifestation (Moneret-Vautrin et al. Allergy. 2005: 60: 443-451). Anaphylaxis presenting in this way must be quickly treated with epinephrine. Prior to the advent of albuterol, epinephrine was the drug of choice for asthma exacerbation. When in doubt, use your epinephrine and call 911.
SM: How real is the threat from so-called "second-hand exposure," like a kiss, to an allergen?
MP: Allergens can be transferred through saliva, so the second-hand exposure threat is real but entirely avoidable. Rosemary Hallett and colleagues at the University of California Davis School of Medicine reviewed data collected on 379 subjects with self-reported immediate nut or seed allergy and found that 20 subjects (5.3%) reported that they experienced reactions from kissing. Most of these reactions were mild but 20% did experience respiratory symptoms (Hallett et al. N Engl J Med 2002; 346:1833-4). Studies in other countries showed that people with food allergies reported that they experienced allergic symptoms after having "close physical contact (for example, kissing) with someone who recently ate something they were hypersensitive to (Eriksson et al. Journal of Investigational Allergology and Clinical Immunology. 2003 13(3):149-154).
In 2006, Maloney and colleagues conducted a study measuring the amount of peanut protein in 1 ml of saliva at certain times after eating a peanut butter sandwich and following various interventions. The study showed that soon after eating peanut butter salivary levels of peanut protein were high enough in some to cause a reaction. Additionally, 13% of subjects had detectable peanut protein in the saliva after 1 hour. No subjects had detectable salivary peanut protein several hours later and after eating a peanut-free meal. This study supports the reports of patients experiencing symptoms after kissing and demonstrates that oral contact with saliva, such as from sharing utensils or cups, can contain significant amounts of allergen and should be avoided. Additionally this study gives some guidance as far as interventions that can reduce the risk of a reaction other than complete avoidance (Maloney et al. JACI. V 118, (3) 719-724).
SM: Broussard quotes a CDC statistician who says, "There are far too few recorded incidents of anaphylactic shock triggered by food allergies to draw any sound epidemiological conclusions: 'We can't find any hard data that supports the severity'."
MP: Studies determining the rates anaphylaxis and death from anaphylaxis have been notoriously difficult to conduct. Until recently, there has been little consensus as to its definition or clinical criteria and it is widely thought that it is underreported and underdiagnosed (Lieberman et al. Annals of Allergy, Asthma & Immunology. 2007;98:519-523).
Statistical information on deaths caused by food anaphylaxis is reliant on appropriate coding, interpretation of death certificates, and the correct diagnosis of cause of death (Neugut et al. ARCH INTERN MED/VOL 161, JAN 8, 2001) .
Even with imperfect methods of data collection and reporting, it is clear from the existing studies that food-related anaphylaxis is a real and growing global issue.
The European Academy Of Allergology And Clinical Immunology recently published a position paper on the management of anaphylaxis in childhood. In this paper, they review several studies supporting an increase in cases of anaphylaxis in North America and Europe. They reference studies that support an increase in anaphylaxis and food allergies in the United Kingdom and Canada.
In looking at the literature, it is clear that food-induced anaphylaxis is very real.
These studies have additionally shown us what risk factors are associated with death:
- delayed epinephrine administration
- being an adolescence or young adult
- peanut allergy
- tree nut allergy
- prior minor reactions
- not asking about ingredients when dining out (Bock at al. Journal of Allergy and Clinical immunology. V119 (4) 1016-1017)
The studies have also shown us what we can do to prevent these tragedies.
SM: Ms. Broussard implied that FAAN's medical board and advising doctors are in some way colluding to disseminate exaggerated evidence. Do you know anything about FAAN's studies' objectivity?
MP: FAAN's medical board and advising doctors are many of the leaders in food allergy and academic allergy and have been responsible for many of the studies leading to information that has dispelled fear and has increased patient safety. The studies published by these authors have been in well respected, peer reviewed journals which are scrutinized by other allergists and experts in the field prior to their publication. This identical process goes for studies that have received funding by FAAN. This process leaves little room for the dissemination of confabulated or manipulated data for self gain.
SM: Ms. Broussard wrote, "...exaggerating the threat may actually do as much harm as the allergies themselves. The peril is now perceived as so great that psychosomatic reactions to foods and their odors are not un-common". Are you seeing this in your practice?
MP: I have experienced fear first hand while watching my own child have a severe, life threatening allergic reaction and not having the appropriate medication that could save his life. After my son recovered and my family had time to process what had happened we put into place well thought-out strategies, based on existing literature, to attempt to prevent this from happening again (avoidance strategies) and in the event that it did, a treatment plan to save his life (allergy action plan and epinephrine). Although we have a healthy respect for his allergy and are vigilant we are no longer afraid.
Pictures of children in gas masks holding food (such as the cover of the November 5, 2007 issue of Newseek) do little to combat fear while at the same time downplaying the very real significance of food allergy and anaphylaxis does little for the emotional or physical wellbeing of the food allergic and their families.
Education and empowerment are key ingredients to combating the natural fear that comes with having food allergies. Misinformation and unaddressed fear has lead to social isolation, anxiety and eating disorders for some. I have met families that kept their children from interacting with others for fear of allergen exposure. With education and support, people with food allergies can have manageable and enjoyable lives.
Dr. Michael Pistiner:
Dr. Michael Pistiner is currently a fellow in Allergy and Immunology at Children's Hospital Boston, Harvard Medical School and is in his final year of the Scholars in Clinical Science Program of Harvard Medical School (masters program in patient based research). Over the last 2 years he has developed a special interest in pediatric food allergy and in the management of food allergy in schools. Within the last 4 months he has seen first hand the critical importance of community wide education as his pre-school aged son experienced anaphylaxis (life-threatening allergic reaction) after eating a small amount of walnut. He is committed to the use of practical food allergy education to replace fear and divisiveness with empowerment, confidence, and unity. Upon completion of his fellowship in July 2008, he will return to New York State and join Allergy & Asthma Consultants of Rockland & Bergen.
1. Yocum MW, Butterfield JH, Klein JS, Volcheck GW, Schroeder DR, Silverstein MD. Epidemiology of anaphylaxis in Olmsted County: A population-based study. J Allergy Clin Immunol 1999; 104:452-6.
2. Weiler JM. Anaphylaxis in the general population: A frequent and occasionally fatal disorder that is underrecognized. J Allergy Clin Immunol 1999; 104:271-3.
3. Wang J, Sampson HA. Food anaphylaxis. Clin Exp Allergy 2007; 37:651-60.
4. Moneret-Vautrin DA, Morisset M, Flabbee J, Beaudouin E, Kanny G. Epidemiology of life-threatening and lethal anaphylaxis: a review. Allergy 2005; 60:443-51.
5. Hallett R, Haapanen LA, Teuber SS. Food allergies and kissing. N Engl J Med 2002; 346:1833-4.
6. Eriksson NE, Moller C, Werner S, Magnusson J, Bengtsson U. The hazards of kissing when you are food allergic. A survey on the occurrence of kiss-induced allergic reactions among 1139 patients with self-reported food hypersensitivity. J Investig Allergol Clin Immunol 2003; 13:149-54.
7. Maloney JM, Chapman MD, Sicherer SH. Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. J Allergy Clin Immunol 2006; 118:719-24.
8. Lieberman P, Decker W, Camargo CA, Jr., Oconnor R, Oppenheimer J, Simons FE. SAFE: a multidisciplinary approach to anaphylaxis education in the emergency department. Ann Allergy Asthma Immunol 2007; 98:519-23.
9. Neugut AI, Ghatak AT, Miller RL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med 2001; 161:15-21.
10. Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G, et al. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy 2007; 62:857-71.
11. Bock SA, Munoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119:1016-8.