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Navigating Food Allergies as a Foreigner the SMART Way

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I was born with numerous food allergies. Growing up in the ‘60s and ‘70s with life-threatening food allergies was incredibly rare, as were the means to managing them. On several occasions, I had to rely on self-induced vomiting for a remedy (epinephrine auto-injectors wouldn’t come onto the market until my early twenties). Thankfully, I grew out of most of my allergies by the time I was a teen, although I remain severely allergic to peanuts, pistachios, and other legumes to varying degrees. After a couple decades managing my allergies, I’d grown pretty adept at navigating the food-allergic life. Then I moved to Southeast Asia.

I flew to Singapore in January 1985, armed with zero knowledge of Southeast Asia or its food (this was well before Google would have informed me that Southeast Asian food includes lots of nuts and legumes). By that time, thankfully, I carried an EpiPen with me, although I had never actually used one.

My first years in Asia were a learning experience in many ways; some of the most “memorable” lessons came from managing my food allergies. To paraphrase Kelly Clarkson: what didn’t kill me made me (slightly) smarter.

For those food-allergic travellers out there, below are five tips that I hope will help you on your journeys.

1.  Study ahead of time

For my kick-off lunch in Asia, I went to a Chinese restaurant with the rest of my team and several clients. The first dish was a cold duck salad, which sounded safe enough. I confidently dug in my chopsticks and took a couple bites. Big mistake. I would soon learn that one of the main ingredients in the dish was chopped peanuts. I stopped eating and found my way back to my hotel. Three days later, after an EpiPen and several bouts of vomiting, I was finally able to get off my hotel room floor. Not a great way to start my Asian adventures.

If I had bothered to do some basic research on the culture’s signature dishes and ingredients ahead of time (and maybe even studied the language), I could have saved myself a lot of trouble. With all the information available on the web nowadays, restaurant research is relatively easy. Find an item on a menu that seems safe and double check with the waitstaff at the restaurant. A chef card translated into the country’s native language always comes in handy too!

2. Medications like epinephrine and antihistamines should always remain close at hand

I remember grabbing a drink one night at a hotel bar with a good friend. I finished my beer before he did (not an uncommon event!), and being the joker that I am, figured I would swap our beer glasses when he turned his head so I could get another swig of beer. Once my lips came into contact with the glass, I knew I was in trouble. He had been eating peanuts! I immediately ran upstairs to my hotel room. Thankfully, I had epinephrine on hand and was able to stave off a more severe reaction.

I now carry medicine with me at all times, in my briefcase, my other briefcase, and my carry-on. I cannot stress how important it is to keep emergency medications on your person. It has saved me on numerous occasions. Traffic can be horrendous in many Asian cities, and I have yet to find any pharmacy in the region that sells antihistamines, let alone an epinephrine auto-injector!

3. Ask questions

When I came to Asia, I was often afraid to ask about ingredients or request that a dish be prepared without certain ingredients. This led to several instances of unnecessary allergic reactions. In hindsight, I should have worried more about my throat (which closes when I eat peanuts) than saving face, which is a big concern in Asia. At times, of course, waiters or friends may not know what goes into specific dishes. In such cases, or anytime you are in doubt, don’t eat it!

There can also be language barriers to overcome. For many servers, English is not their first language. As such, I have found that I need to be very specific with my questions—instead of asking about legumes, I ask about peas, beans, bean sprouts, bean curd, and bean paste—use local terms as much as possible!

4. Remember the hidden ingredients

Over the years I’ve had several food experiences that resulted in urgent visits to the doctor and/or hospital due to anaphylactic reactions. Often, these visits were because I ate a seemingly safe dish that had a sauce or spread containing nuts or legumes.  

Once at a hawker centre, I ordered a seemingly safe plate of satay. Being much wiser after having spent a few years in the region, I avoided the peanut dipping sauce. Unfortunately, despite only eating the skewered meat, I experienced an allergic reaction. I later learned that the satay chef had used peanut oil to baste the meat, and while peanut oil is nowhere near as deadly for me as peanuts, I still had a reaction.

In another instance, I ordered a basic chicken sandwich only to discover after taking a bite that it contained a pesto sauce made with pistachios. I also remember eating Indian food and wondering why I kept getting sick afterward. Eventually, I found out that papadum (which is served with many meals) is often made with ground lentil or chickpea flour. Thai green curry can include green beans, and some chili crab is made with peanuts.

In sum, there’s more than meets the eye for many food items in Southeast Asia. Those “hidden” ingredients? They are often the most dangerous ones.

5. Tell others

When travelling, especially with a group, I often kept quiet about my allergies as I did not want to inconvenience others. This occasionally backfired when I ended up having a reaction. I soon realized that telling the people you know is essential when living with a food allergy—in the case of a severe reaction, they may need to assist in administering your medications.

Often, I’ve found that friends and family are more than willing to omit certain ingredients or make special arrangements to accommodate allergies. I have also found that many restaurants—and even some hawkers—are quite willing to accommodate my special requests such as noodles without bean sprouts or fried rice without peas.

In summary, when travelling abroad, remember that food is a major part of every culture and that you can enjoy it as long as you are SMART about it: Study ahead of time, keep Medication close at hand, Ask questions, Remember the hidden ingredients, and Tell others.

- Nels Friets

 

Nels is the Co-Founder & Vice Chairman of tryb Capital, a Singapore-based financial investment group that invests in emerging financial technology solutions. Nels is also an investor in Allergy Amulet with the Bulldog Innovation Group, a network of Yale alumni investors.

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Food Allergy Numbers: Why the Mystery?

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As someone who has a personal and professional connection to food allergies, I probably talk about the subject more than most. During these conversations, I’m often asked questions about food allergy science, management, and awareness. As a result, I’ve grown pretty proficient at fielding most food allergy questions thrown my way (at least I’d like to think so ☺). However, there’s one question that I dread answering since my response will almost surely disappoint. Here it is: How many people have food allergies?

The answer? It’s complicated. Not what you were hoping to hear, right? Read on, I promise to share some great food for thought on why this question has no easy answer!

First, let’s review some commonly referenced food allergy statistics:

-       As many as 15 million Americans have food allergies

-       Approximately 9 million adults have food allergies

-       Approximately 5.9 million children have food allergies (1 in 13, or 2 in every classroom)

-       Between 1997-2011, food allergy prevalence among children increased by 50%

-       Food-allergic children are 2-4 times more likely to have related conditions such as asthma (4x), atopic dermatitis (2.4x), and respiratory allergies (3.6x)

Now let’s dig a little deeper. A 2011 study published in Pediatrics found that the prevalence of allergy among food-allergic children was highest for peanut (25.2%), followed by milk (21.1%), and shellfish (17.2%). The results of a recent national survey of 53,000 families showed that peanut allergies in children have increased 21% since 2010, and that 45% of adults develop at least one allergy after age 17—which is surprising, considering food allergies are commonly thought to present themselves in childhood.

These stats all sound pretty solid, no? Well, they're not exactly. Here’s why.  

Numerous variables come into play when discussing prevalence statistics for food allergies, making firm figures difficult to come by. To name a few:

-       Old data. A lot of the figures referenced above are 5-10 years old. This past week, the New York Times published an article citing a wheat allergy statistic that is nearly a decade old (and this appears to be the most current figure!).

-       Self-reported data. Most food allergy research is collected through self-reported diagnosis (individuals are polled and asked to identify their food allergies). Some have been diagnosed by allergists, but others may have had one reaction their whole life and attribute that reaction to a specific food that they’ve avoided since (as one example). Many folks also mistake a food allergy with an intolerance, which can further muddy the data.

-       False positives. The best diagnostic technologies out there aren’t always 100% accurate, as we discuss in two earlier posts: Food Allergies Today: An Expert Q&A and More Tools, More Problems? Food Allergies Since 1960. False positives are frequent and regularly occur during allergy testing. For example, my daughter consistently tests moderately allergic to almonds and sesame with the ImmunoCAP test (a test that measures the body’s level of allergen-specific IgE antibodies), but she frequently eats both foods with no symptoms.

In short, it’s hard to pin down just how many Americans (and individuals worldwide) have a food allergy, making this question an especially tough one to answer! As we advance our understanding of food allergies, one can only hope that this knowledge helps us to better diagnose, manage, treat, and prevent.

In the meantime, continued research, emerging therapies like OIT, and technology will lead the charge and give hope to this growing population.

-       Meg and the Allergy Amulet Team 

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Amaretto Makes Me More Than Sour

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Imagine walking into a bar and discovering that three of the liquor bottles behind the counter are laced with cyanide. You’d probably look elsewhere for a drink (right after a few expletive-laced remarks to management and a call to the authorities). But for me, there is no elsewhere. This is every bar I go to for a drink.

Most people don’t think of alcoholic beverages as posing a risk to those managing food allergies, but for someone like me, who is deathly allergic to tree nuts, amaretto (almond liquor), Frangelico (hazelnut liquor), and Dumante (pistachio liquor) may as well have a skull and crossbones on the label. One sip and I’d be hightailing it to the hospital.

Dozens of popular cocktails contain these ingredients, so rather than risk ordering the wrong drink, or having a new bartender accidentally grab the wrong bottle, I avoid cocktails altogether and stick to beer or wine.

But that wasn’t always the case.

Over the years I’ve had a few close calls. At a party in my early-20s, someone handed me a shot. Right before tossing it back, I turned to the guy who handed it to me and asked him what it was. Amaretto, he replied. To this day, I look back at that harrowing moment and thank the high heavens that I knew amaretto was almond liquor. Had I not, that night would have probably played out very differently. 

Drinking presents unique risks to those managing food allergies—it impairs your judgment AND compromises your ability to evaluate risk. You’re more likely to carelessly toss back a friend’s French fry (guilty) or accept a drink without knowing its contents (also guilty). For this reason, excessive drinking is particularly risky for those with food allergies, and is best avoided. It’s also important to have survival strategies in place.

Here are a few of mine:

1. Look up the names of all liquors and drinks you need to steer clear of and commit them to memory (and keep a cheat sheet in your bag or wallet)!

2. Stick to drinks you know are safe, and double check their contents with the bartender before taking a sip.

3. If you’re drinking and eating, avoid even moderately bold food choices and stick to low-risk foods. I tend to go for pizza, as it poses a lower risk for my allergies. Pro tip: pack a snack in your bag or purse before heading out for the night!

4. If someone orders you a shot or cocktail, politely pass the drink along to another thirsty patron.

These bar tricks have served me well over the years, and they’re ones that I wish someone had told me earlier on in life. In the end, the key to avoiding these dangerous drinks is properly navigating and mitigating the risks.

- Abi and the Allergy Amulet Team

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Understanding More, Fearing Less

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“Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.”    – Marie Curie

Who better to listen to on the topic of fear than the first female scientist to win a Nobel Prize (twice!)? Curie had to overcome quite a few fears in the male-dominated science profession before winning those awards. She was also the daughter of a proud papa named Wladyslaw, a math and physics teacher (her mother died when she was ten), which is a nice segue to another proud papa: me. My name is David. I’m a 43-year-old corporate attorney, private equity and venture capital investor, and the father of three wonderful daughters. My daughter Caroline is not a scientist (yet), but like Curie, she confronts fear and hostile environments every day. She is severely allergic to peanuts and most tree nuts.  

As any parent of a child with a food allergy will attest, food outings are an exercise in fear. Even though my wife and I have no allergies, we experience this fear vicariously through Caroline daily. I can see the fear in Caroline’s eyes nearly every time we dine out. For a ten-year-old girl, this fear can be debilitating, frustrating, confusing, and embarrassing all at once. Caroline counts on us to always protect her, making us promise that she won’t get “hurt” when she eats out with our family. Caroline is good at math. Even at ten, she knows that getting it wrong even 0.1% of the time can be deadly. It is our very own David and Goliath story: my fragile young daughter against the fear of uncertainty. 

On a recent trip to our local ice cream parlor, we loudly (in keeping with custom) informed the teenage server of Caroline's peanut and tree nut allergies as we placed the orders for our three young daughters. The staff proceeded to assure us every precaution and make her ice cream cone in a separate, allergy-free area. These precautions always make me feel better, but the fear is constant, like white noise in the background.

First to receive her double-scoop cone was our eldest daughter, Ashley. Within seconds of handing her the cone I was startled to attention, "Dad, this tastes like peanut butter!" We didn't order a peanut butter cone for Ashley. Ashley has no food allergies, however, we never allow our other children to eat peanuts or tree nuts around Caroline. Family rule! I took a bite and sure enough, a strong flavor of peanut butter filled my mouth. Disappointed, we immediately informed one of the servers, who shrugged it off as if we had just informed her that she had forgotten to add green and red gummy bears to the cone. "Whoops, I guess we put the wrong thing in the order, sorry." I was stunned, but frankly, over the years I’ve grown accustomed to non-allergic parents, teachers, and servers acting like food allergies just aren’t a big deal. What if that server had accidentally given Caroline that cone? I clutched my daughter’s EpiPen case and shuddered to think what would have happened if she had been the one on the receiving end of that double-scoop chocolate cone. Uncertainty and fear gripped my insides. 

What’s a father to do? 

First, I make a point of frequenting stores and brands that promise nut-free facilities. The only “nut-free” bakery around is the next town over, but I think it’s worth the trip. I also support nut-free brands to ensure they stick around.

Second, I have spent the last five years of Caroline’s life trying to teach her to look out for herself. It’s a lesson I hope she will take with her when she is a teenager dining out with friends, and ultimately when she leaves our house and has to fend for herself. For my wife (Julie) and me, questions and doubts continually spin through our minds: Will she remember to carry her EpiPen at college? Will she know to diligently check food labels when we’re not around? Will she ever be too embarrassed to speak up about her food allergies when out with friends? To combat these concerns, we always try to make sure we’re helping her build the skills she needs to manage her food allergies solo.

One recent evening, while dining out at a local farm-to-table restaurant, I discovered half of a walnut in my nut-free pasta. While once again surprised and scared, it was a stark reminder of how easily cross-contact occurs. Enter Allergy Amulet, an early-stage technology company trying to create greater food transparency and help individuals with food allergies feel safer about the foods they eat. I believe that technology holds the key to helping her defeat her Goliath. That’s why Julie and I are proud investors in the company. 

Perhaps one day in the near future, my little wonder woman will not be brandishing a primitive sling-shot to slay the giant, but rather, an Amulet. Perhaps science will help her overcome her fears, and help her understand more, and fear less.

David would like to thank his wife Julie for her careful edits and contributions to this piece.  

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Cross-Contact or Cross-Contamination: What’s the Difference?

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I’ll be honest with you: distinguishing between cross-contact and cross-contamination used to throw me off. Many people in the food allergy community (my past-self included) often mistakenly use the terms interchangeably.  

The confusion is so widespread that even food manufacturers and allergists mix up the two. In fairness, cross-contact is a new(ish) term, so some have gotten into the habit of labeling everything involving inadvertent food exposure as cross-contamination. “I’ll be the first to admit that I don’t always use the terms correctly,” says allergist Dr. Jordan Scott. “Many of us were trained to use cross-contamination to refer to allergens inadvertently getting into another food source.”

To help clear up some of the confusion, we’re breaking down the difference between the two terms in this post.

Let’s start with some examples.

Cross-contact: This occurs when a food allergen in one food (let’s say milk protein in cheese) touches another food (let’s say a hamburger), and their proteins mix, transferring the allergen from one food to another. These amounts are often so small that they can’t be seen!

In this example, let’s assume I have a severe milk allergy. If the cheese touches the burger, cross-contact has occurred. Even if the cheese is removed from the burger, trace amounts of the milk allergen likely remain on the burger making it unsafe to eat and posing the risk of an allergic reaction.

It’s important to note that most food proteins (with few exceptions, like heat labile proteins) CANNOT be cooked out of foods, no matter how high the temperature. When our daughter underwent oral immunotherapy for her peanut allergy, we were given the option to bake the peanut flour into muffins for her to consume. We were told that the high oven temperature would not affect the protein structure of the peanut flour.

Cross-contamination: Cross-contamination occurs when a bacteria or virus is unintentionally transferred from one food product to another, making the food unsafe. The key mark of distinction is that cross-contamination generally refers to food contamination, not food allergens.

A couple examples: you cut raw chicken on a cutting board before you put it on the grill. You then cut peppers on that same cutting board. The raw chicken juice touches the peppers, therefore posing a risk for bacteria. Or say you purchase a cantaloupe that unknowingly has listeria. The knife used to dice up the melon is now a vehicle for cross-contamination. Unlike cross-contact, properly cooking contaminated foods generally CAN eliminate the food-borne offender.

Is it all making sense now? In short, when referring to food allergens, use cross-contact, and when referring to food-borne bacteria or viruses, use cross-contamination. Easy peasy.

We hope our explanation cleared up any confusion. Now that you’re a cross-contact pro, here’s a guide with tips on how to avoid cross-contact.

Want to discuss this topic further? Still confused? Feel free to reach out to me at mnohe@allergyamulet.com. I’m always game for a good food allergy chat!  :)

-       Meg and the Allergy Amulet Team

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