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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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Whole Foods for Thought: The Debate Over Quality Versus Quantity

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You’ve probably heard by now that Amazon bought Whole Foods. The latter’s shareholders recently approved the transaction, and assuming regulators sign off on the deal, the creators of Man in the High Castle and the sellers of the Squatty Potty will now be joining you at the dinner table. Bon appetite :)

On the one hand, the deal is expected to make shopping at Whole Foods more affordable. Awesome! Consumers are already seeing markdowns on several food items including butter, bananas, and eggs. But there’s one nagging question out there that looms large: where would that money otherwise have gone? To the farmers? To its employees? And how will Amazon’s takeover impact the quality of food and the values that Whole Foods has stood by all these years?

At Allergy Amulet, we care about food quality and a healthy work environment. We also care about high-quality food being accessible and affordable to everyone! So naturally, we’ve been following this deal closely. 

According to Jeff Wilke, CEO of Amazon’s worldwide consumer business, “[e]verybody should be able to eat Whole Foods Market quality—we will lower prices without compromising Whole Foods Market’s long-held commitment to the highest standards.” That’s all well and good, but there’s one problem with that statement: the inverse relationship between quality and quantity.

California’s first organic strawberry farmer, Jim Cochran, confronted this dilemma at his farm. To satisfy increasing demand for his strawberries at Whole Foods, Jim expanded his farm from four to 24 aces. Recognizing the problem between increased yield and berry quality, he scaled back to 12 acres to focus on quality over quantity.

Is it possible to produce high-quality strawberries on a massive scale?

Here’s an interesting fact: Americans spend less on food than people in any other country in the world. Indeed, most countries spend over 10 percent of their incomes on food, whereas Americans spend closer to 6%. Why is our food so cheap?

As Michael Pollan points out in Omnivores Dilemma, food is cheap because the true costs have been externalized—we still pay them, but instead of paying at the register, we pay in the form of rising obesity rates, cheap labor, and lax environmental and safety regulations. Consider too that between 1995 and 2010, the American taxpayers gave the agriculture industry roughly $262 billion in subsidies. This begs the question: is our food really that cheap?

Let’s say Amazon decides not to compromise on quality: who then is getting the short end of the stick with the lower price tag? There is some concern that the Whole Foods culture and workplace environment will soon change with Amazon in charge. After all, Whole Foods salaries average around $18 an hour, whereas Amazon pays on average $12 an hour (a figure below the national average). Amazon also has a reputation for grueling work conditions at its warehouses, and reports of intense surveillance and monitoring of its employees—another cause for concern.

At Allergy Amulet, our work lies at the intersection of food and health. We care about food quality and safety; we also appreciate that good food often costs more, and is not accessible to many Americans. For this reason, the conversation around food quality is an important one. Everyone deserves high-quality, nutritious food, but the question stands: how do we make that food affordable to everyone without compromising on quality or forfeiting the values underpinning good food like well-paid farmers, safe working conditions, humane animal treatment, and sustainable farming practices?

Hopefully, Amazon has the answer.

- Abi and the Allergy Amulet Team

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You Down with EoE? No Thanks, Not Me.

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Every now and again our team at Allergy Amulet likes to post blogs about lesser-known conditions that affect the food allergy population (our people)! One such blog, I’ll Take My Allergies Medium Rare, covers some uncommon (but very real) forms of allergy. Today’s installment is no different! Have you ever heard of a condition called Eosinophilic Esophagitis (E-o-sin-o-fill-ik Uh-sof-uh-jie-tis), or EoE for short?

What is it?

If you have EoE, a large number of white blood cells (eosinophils) build up in the lining of the esophagus (the tube that connects your mouth to your stomach). This buildup is a reaction to food, airborne allergens, or acid reflux, and can inflame and injure esophageal tissue. EoE is a recognized chronic allergic/immune condition, and is not typically outgrown (but it can be managed)! EoE is a relatively new disease, as it has only been identified in the past two decades. Accordingly, there is still much to learn about this complex condition.

Who does it affect?

EoE affects approximately 1 out of every 2,000 people in the United States. In recent years, allergists and gastroenterologists are seeing an increasing number of patients with EoE—this is presumably due in large part to greater physician awareness about the condition. Most patients with EoE are considered atopic, meaning they have a family history of allergies, asthma, or symptoms of one or more allergic disorders. These can include food allergies, eczema, seasonal allergies, and asthma. For patients with environmental allergies, their EoE may be worse during pollen season. Allergic reactions to food are the main cause of EoE in many patients, and foods such as dairy, soy, wheat, and eggs are often the main culprits. Interestingly, according to Dr. Jordan Scott of Boston Children’s Hospital, the development of EoE has occurred as a side effect of oral immunotherapy for food allergies in up to 3% of cases.

What are the symptoms?

EoE symptoms vary depending on age. Infants and toddlers may refuse food or fail to gain weight. School-age children often experience difficulty swallowing, vomiting, or have recurrent abdominal pain. Teens and adults generally have trouble swallowing, especially dry or dense solid foods. In some cases food can get trapped in the esophagus, which can lead to choking.   

How is it diagnosed?

There are certain criteria for diagnosing EoE that most allergists, gastroenterologists, and pathologists agree on: symptoms consistent with EoE, an upper endoscopy procedure (lets the doctor see what’s happening in your esophagus), and an esophageal biopsy (tissue samples of the esophagus are taken and analyzed). A specialist may also recommend further evaluation (e.g., a gastroenterologist may refer a patient to an allergist for food allergy testing and vice versa).

Is there a silver lining? 

The rise in EoE cases has led to greater physician awareness and further research around the condition. Additionally, a wide variety of treatments have been identified for those managing EoE, such as:

1.    Empiric elimination diet—removing major food allergens (e.g., dairy or wheat) from your diet and gradually adding them back in one at a time under close physician watch and guidance. This diet is often most successful with the help of a dietitian, as it can be tough to manage.

2.    Elemental diet—all sources of protein are removed from the diet and replaced by an amino acid formula, oils, and simple sugars. This treatment is often reserved for children with several food allergies who have not responded to other treatments.

3.    Medical therapy—swallowing small doses of oral corticosteroids has proven effective for managing inflammation. Proton pump inhibitors are also used to control acid production. 

Each of these treatments has its advantages and disadvantages, so it’s helpful to first discuss them with your physician before trying any one approach. One challenge with treatment, according to Dr. Scott, is that patients must typically undergo multiple endoscopy procedures to ensure that esophageal inflammation is improving with meds, dietary avoidance, or both.

The good news is that you don’t have to go it alone! There are numerous support groups and organizations out there that can help, such as APFED and CURED. When it comes to understanding and managing immune conditions, having a trusted support network is key!

- Meg and the Allergy Amulet Team 

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How to Save a Life

Abi and Sakura at Middlebury College in 2007.

Abi and Sakura at Middlebury College in 2007.

Have you ever stabbed anyone? I have.

I stabbed my friend and Allergy Amulet Co-Founder Abi Barnes with an EpiPen in the summer of 2007.  

Abi and I spent that summer at Middlebury College, where I had just wrapped up my sophomore year. Alongside roughly 100 others, we immersed ourselves in an intensive Mandarin language program, pledging not to speak English for the program’s nine-week duration. Abi’s dorm was across the hall from mine, and we soon became good friends. We watched movies, went on runs, gossiped and joked, but always in this foreign tongue that consumed every part of our daily lives. We couldn’t even read in English, forcing several of us to secretly pass around an English version of the last Harry Potter book, which had just been released—no one wanted to attempt reading that in Chinese.

One particular summer day, we finished up our morning classes and walked over to the dining hall. We were now several weeks into the program, so I was used to seeing Abi meticulously look for nuts on the ingredients list of every item on the self-service buffet menu. She and I chatted away while she seemingly nonchalantly searched for ingredients that could kill her.

Among the various menu items was a grilled, flaky white fish with a brown sauce that we both opted for that day. Shortly after we sat down and started eating, Abi suddenly froze. “Oh my god,” she said; I was alarmed. Not because she turned pale, or had a look of panic in her eyes, but because she spoke English within earshot of other students and teachers.

《什么?》What?” I said.

“Oh my god.”

Worried about Abi getting in trouble I asked,《你为什么说英文?》“Why are you speaking in English?”

“No seriously, I can feel it. It was the fish sauce. I didn’t check it. I know it. I can feel it. I need my EpiPen,” she said in a panicked manner.

《在哪里?》Where?

“We have to go. It’s in my room.”

Abi grabbed my hand and we ran across campus to our dorm. Once in her room, she tossed me the EpiPen in its original cardboard packaging and said, “Read the instructions.” I learned later that it’s always better to let someone else administer the epinephrine­ needle. I also learned that it’s good to have someone with you—which makes sense, considering that someone having an allergic reaction could pass out.

At this point, we were speaking only in English. I remember my hands shaking while I held the instructions and found myself reading them over and over again. Meanwhile, Abi was popping Benadryl tablets like pink Tic Tacs. She extended her paper-white thigh to me and said, “You’ll need to do it with full force.”

So I took a generous upward swing and stabbed her. Bright red blood trickled down her upper thigh. We then rushed to the hospital.

Many hours later, when the hospital determined she was safe to leave, our friend drove over to pick us up. We got into the car and The Fray’s “How to Save a Life” came on the radio. We laughed and heaved a collective sigh of relief.  

It wasn’t until days later when we went swimming in a nearby lake that I realized the force of stabbing her had left a black and blue bruise bigger than my hand on her thigh. I knew that food allergies were dangerous, but this incident with the fish sauce was a terrifying reminder of that fact. I remember Abi was completely wiped out after the ordeal, and to think that she has to constantly look out for dangers lurking in foods must be exhausting.

Fast forward a decade and I’m currently the Chief Operating Officer of a family-owned Japanese restaurant group in New York City. At each of our 15 locations, our staff is trained to manage food allergies. I’d like to think that we’ve educated our staff about food allergies since opening our first location in 1984, but the reality is that dining out is always a potential minefield for individuals like Abi. It makes sense that she came up with the idea for Allergy Amulet.

Stabbing Abi in the summer of 2007 will forever stay with me as a reminder of the importance of food allergy awareness and education. I also hope that incident will remain my first and last stabbing.

 

Abi’s longtime friend, Sakura Yagi, wrote this post. For additional information on the proper use of epinephrine, please read here

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More Tools, More Problems? Food Allergies Since 1960

This guest post was written by Theresa MacPhail—assistant professor in the Science, Technology, and Society Program at Stevens Institute of Technology. 

Last December, I wrote a blog post about the early history of food allergies from the 1800s through the 1960-70s. In this installment, we’ll examine more recent food allergy chronicles, current treatments, and diagnosis debates. Despite advances in our understanding of the immune system, and promising developments in allergy-related technologies (like the Allergy Amulet), the lack of a cure or effective treatments for food allergies persists.

The Discovery of IgE

Immunotherapy treatments were first tested in animals, and then cautiously applied in clinical settings to treat both respiratory allergies and food allergies beginning in 1911. The risk of an accidental anaphylactic response was, and is, ever present. Much of the early allergy testing and treatment remained unchanged until the mid-1960s, when two separate research teams discovered immunoglobulin E, or IgE—a molecule that naturally forms in human blood.

IgE’s discovery led to a greater understanding of the inflammatory response that follows allergen exposure, sparking more research around the cause of allergic reactions. By 1975, the first commercially available and reliable blood test for IgE became available for clinical use. IgE testing quickly became a significant aid in allergy diagnosis, since an elevated presence of IgE levels in the blood often indicates a food allergy.

IgE has played an enormous role in subsequent allergy research, diagnosis, and treatment. However, while IgE tests provide information as to the likelihood of having a food allergy, 50-60% of IgE blood tests yield a “false positive” result, creating a great deal of uncertainty in diagnosis. IgE as an allergy biomarker is accordingly far from perfect.

Food Allergies - A Rising Prevalence?

If you follow the news or social media, or have a young child in the school system, it certainly seems that food allergies are on the rise. Although food allergy awareness has increased over the last decade and has become a more popular topic of conversation, the food allergy prevalence rate has been difficult to measure with confidence.

Figures on the national and global food allergy population are unsettled. This is largely because the numbers rely on multiple data sets collected across different methods and research groups. Official estimates place the figure at around 15 million. Adding to this confusion is the difficulty in confirming the presence of an allergy with current diagnostic tools (often IgE testing, discussed above). The majority of food allergy and food intolerance cases depend on self-reporting and sometimes self-diagnosis—and those numbers fluctuate greatly. A recent paper looking at multiple different allergy studies found that “[s]elf-reported prevalence of food allergy varied from 1.2% to 17% for milk, 0.2% to 7% for egg, 0% to 2% for peanuts and fish, 0% to 10% for shellfish, and 3% to 35% for [other foods].” A 2013 paper further suggested that “at least 1%–2% and up to 10% of the US population suffers from food allergies," which based its findings on "self-report, skin prick test (SPT), serum-specific IgE (sIgE), and oral food challenges (OFC).” These reports show that food allergy populations vary based on allergy type, reported severity, geographic region, study design, and testing method.

In short, with no easy and standardized way to diagnose food allergy cases, it is difficult to confirm and measure the perceived rise in the food allergy population.

The LEAP Study and the Future of Oral Immunotherapy

Perhaps the most significant study on food allergy in the last 50 years is the Learning Early About Peanut Allergy (LEAP) study by the Immune Tolerance Network. In this study, infants at a higher risk of developing a severe allergy to peanuts were randomly assigned to one of two groups: one that would avoid ingesting peanut-containing foods until age 5, and one that would consume a peanut-containing snack (~6 grams of peanut protein) with three or more meals per week until age 5. Of the children who avoided peanut, 17% developed a peanut allergy, compared to only 3% of the children in the control group. In a press release for the study, one of the researchers noted how for decades allergists have recommended that infants avoid consuming allergenic foods, and this study "suggests that this advice was incorrect and may have contributed to the rise in [] peanut and other food allergies.” Indeed, the LEAP study overturned decades of prior advice and shook the allergy research community. The study also gave credence to one of the oldest forms of allergy treatment: immunotherapy. 

After a decade of research, oral immunotherapy is becoming more widely accepted as effective for the most common food allergies (e.g., peanut), but little is known about its long-term effectiveness. If you’re not familiar, oral immunotherapy (OIT) is a method of food desensitization that involves re-introducing the immune system to the allergenic food in gradually increasing amounts over time, with the goal of eventual tolerance. Although researchers are optimistic about its potential, it is not without its drawbacks. You can learn more about OIT in Allergy Amulet’s blog post here.

The Promise and Peril of Epinephrine

Epinephrine (the hormone adrenaline) was first discovered in 1900 and marketed to treat asthma attacks and surgical shock. By 1906, with the development of a synthetic version, the drug was in common use by clinicians to treat severe asthma attacks. Immunologists and allergists experimented with dosages in the decades following, standardizing treatment protocols.

In 1975, a biomechanical engineer developed the first auto-injector syringe for the military, which was then adapted for use with epinephrine. It wasn’t until 1987, however, that the FDA approved the first epinephrine auto-injector for the general public. Epinephrine auto-injectors proved so effective—and the dosage delivered was so consistent—that it became the standard prescription for anyone suffering from a severe allergy. By the 1990s, food allergy patients were advised to carry one at all times for their safety.

In 2016, the mother of a child with a severe food allergy began a campaign against the dramatic rise in price of one of the most popular epinephrine auto-injector brands: EpiPen. The price of EpiPen surged between 2004 and 2016 – increasing from $100 to over $600. With few competitors on the market, Mylan Pharmaceuticals, the manufacturer of the EpiPen, felt no need to lower its prices. The story went viral and sparked debate about pharmaceutical industry pricing policies and access to affordable healthcare. Since the scandal broke, there has been a call to develop alternative and less expensive epinephrine auto-injectors.

The Epi-Pen story—and this post—highlight the urgent need for greater investment in allergy research and innovation. Let’s hope that with new advancements in the coming years, food allergy itself will be history. 

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Smoothie Bars & Ice Cream Parlors: A Potential Allergy Nightmare

Standing in line at Trader Joe’s last week, I noticed a sign alerting shoppers of a recent recall of their Matcha Green Tea Ice Cream due to “the potential presence of small metal pieces in the product.” If you’re thinking, “That’s nuts!” You’re right—although in my case, either would probably be just as harmful (I’m fatally allergic to nuts). 

The idea that some small dangerous object could be hiding in your food is not a far-flung concept for the food-allergic. If you’ve never lived with a food allergy, or cared for someone with a food allergy, it’s hard to appreciate the dangers that lurk behind seemingly innocent foods. And they often hide in the most unsuspecting places. Two such places are ice cream parlors and smoothie bars—or what UCLA pediatric allergist Dr. Maria Garcia-Lloret refers to as “allergy minefields.”

If you’ve ever been to an ice cream parlor with a food allergy, you know that the only thing separating a scoop of almond praline swirl and plain vanilla is typically a bucket of water—and for someone with a severe food allergy, that’s not going to cut it. Trace amounts of a food allergen, as low as parts-per-million levels, can be fatal for those with a severe food allergy.

These days, many popular smoothie bars offer “protein boost” health supplements, which often include tree nut and peanut powders (or other popular plant-based powders like chia seed, brown rice, hemp seed, green pea, sunflower seed, or pumpkin). These powders can have incredibly high allergen concentrations, which is to say, the slightest trace of one of these powders can trigger a severe reaction.

Dr. Garcia-Lloret, a professor of pediatric allergy at the Mattel Children's Hospital at UCLA and a pioneer in the food allergy community, has been treating food-allergic patients for nearly 20 years. Needless to say, she’s seen countless allergic reactions and anaphylactic episodes over the years. When we spoke, she offered a cautionary tale when it came to these cold summer treats. "Based on my experience, those with food allergies should be wary of ice cream parlors and smoothie bars, as they don't usually think of these types of establishments as hazardous, and they lower their guard." She also mentioned that teenagers are particularly vulnerable in these settings, noting how carefree summer outings with friends too often lead to the emergency room. 

That said, if you have a food allergy but still need your cold smoothie or ice cream fix (like me!), the most important thing you can do is know all of the ingredients present at the facility, and make sure you’re comfortable with the measures the facility takes to prevent cross-contact. Additionally, here are a few other tips:

1.     Ask the smoothie bar to use a freshly washed blender. Double-check their sanitizing process to ensure the blender has been thoroughly cleaned and there is no lingering allergen residue.

2.     Make sure the ice cream scoop has been thoroughly washed since its last use.

3.     If the person behind the counter wears gloves, ask them if they’d kindly change their gloves (or wash their hands if they’re not wearing gloves, as appropriate). Many of these establishments offer other foods as well, so this is a good way to ensure you’re avoiding cross-contact.

On the upside, many ice cream parlors and smoothie bars are becoming increasingly allergy-conscious, and are implementing more stringent protocols to accommodate those with severe food allergies. Let’s be honest, what kid (or adult) doesn’t want to participate in this classic summer pastime? If you’re now wondering, Where do I find hidden these allergy-friendly gems?! Spokin recently compiled this short list of some the nation’s most allergy-friendly ice cream parlors! Or, if you’d prefer to purchase a pint instead, check out this list of top allergy-friendly ice creams!

Wishing you all a SWEET summer!

- Abi and the Allergy Amulet Team

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