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peanuts

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Everything’s Coming Up… Rotten

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Something in our world is changing. Our bodies are rejecting the food we eat. Even the experts don’t really know why.

In January, Netflix debuted an original six-part documentary series titled Rotten. The series travels deep into the heart of the food supply chain to reveal more than a few unsavory truths about what we eat. Of particular interest to the Allergy Amulet team was the second part of the series: The Peanut Problem.

This episode surveys experts across different fields to understand why the US has witnessed a surge in food allergies in recent decades—more specifically, to peanuts.

According to Dr. Ruchi Gupta of Lurie Children’s Hospital, one in four kids with a food allergy is allergic to peanuts, and more than half of those kids have experienced a life-threatening allergic reaction. 

The problem has become so widespread, in fact, that the peanut industry is beginning to take action. Peanut farmers have started pouring millions of dollars into food allergy research to help address the problem. To date, the National Peanut Board has donated approximately $22M to food allergy research. One company is even developing an allergy-free peanut, which could be on the market as early as next year. 

Peanuts are in trouble. In only a few years they have seen their reputation transform.

The Rotten series artfully underscores the risks that dining out presents. Responsible for nearly half of food allergy fatalities, restaurants have emerged as battlegrounds for those managing food allergies. Chefs must routinely navigate these food allergy minefields—and most kitchens are ill-equipped for the job.

We bend over backwards to make sure our food is safe. Bend over backwards because it’s life and death. – Ming Tsai, Head Chef, Blue Dragon

Surprisingly, no one really knows what’s going on. Doctors are still struggling with what seems to be a simple question: why the increase in food allergies? And why now?

According to Dr. Gupta, it’s likely a combination of genetics and our environment, with environmental factors triggering changes to the composition of our microbiome.

Getting your immune system to know this is ok, that in and of itself would be incredible. – Dr. Ruchi Gupta, Lurie Children’s Hospital

Some of the leading theories discussed in this segment, which we also discuss in an earlier post, include:

-       Microbiome changes: how antibiotic usage in infants and other environmental factors have affected our gut bacteria.

-       Clean state: the idea that the modern world is too clean and the lack of early exposure to dirt, bacteria, and animals weakens the immune system.

-       Early avoidance: for the past decade allergists have advised parents to avoid introducing allergenic foods early in life—it turns out early introduction may prevent the onset of food allergies.  

Much remains uncertain as to the reason for the rise in food allergies, and there is not yet a cure on the horizon. In the interim, management tools, standard precautionary measures (always carry epinephrine!), and treatment options like OIT can make living with food allergies a little easier.

We highly recommend carving out some time to watch this series—you won’t be disappointed.  Whether you have a food allergy, care for someone that does, or simply care about the food you eat—this series has something for everyone.

-       Meg and the Allergy Amulet Team

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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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OIT—Is It For Me?

Feeding your peanut-allergic child peanuts is not easy as a mother—I would know, I do it every day. Your instincts as a parent are to keep your child as far out of harm’s way as possible. But in today’s world, peanuts may be the best management tool we have for my peanut-allergic child.

Let me explain.

My daughter was born with a severe allergy to peanuts and tree nuts. For the first three years of her life, we strictly avoided these foods. She’s now four. Last April, we agreed to undergo an oral food challenge at her allergist’s office to find out if she was still allergic. Her peanut blood test numbers had dropped considerably—this blood test measures levels of Immunoglobulin E (IgE) to individual allergens in the body. IgE is the antibody that triggers food allergy symptoms. Plus, she hadn’t been exposed to peanut since she was a baby. Unfortunately, the oral food challenge outcome wasn’t as we hoped: after ingesting ¼ of a peanut, split into three gradually increasing doses over a 45-minute period, she experienced an anaphylactic event and we had to administer epinephrine. It was an emotional day, to say the least.

After discovering that she was still severely allergic to peanuts, we decided to explore oral immunotherapy: 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.

For our family, the results have been life changing. The same little girl that reacted to ¼ of a peanut now eats 12 peanuts daily with zero symptoms. But OIT is not necessarily for everyone, so I’d like to share our family’s journey and offer some insights into the process so that you can determine whether it’s a good fit for you or your child.

If your allergist doesn’t have a clear picture of your allergy severity, treatment may start with an oral food challenge. Once the individual has been identified as an OIT candidate, they are typically provided a juice-like beverage containing tiny amounts of the allergen. This beverage is consumed during the same two-hour period every day. Depending on how quickly a patient builds up a tolerance, your allergist may recommend coming in every week or two for an “updose”—an increase in the amount of allergen consumed. As the immune system grows more tolerant, the patient eventually moves to a powder form (which is typically sprinkled onto food), and finally to solids (e.g., whole nuts).

Importantly, OIT requires a considerable time commitment. Although updosing typically occurs every week or two, the allergen must be consumed every day to build and maintain tolerance. OIT also places constraints on physical activity. During OIT, the patient can only engage in calm, quiet activity half an hour before dosing, and at least two hours afterwards (during their observation period). This ensures that the immune system doesn’t get “revved up” unnecessarily and trigger an allergic reaction.

Is OIT perfect? Not quite. For the foreseeable future, my daughter must eat 12 peanuts with a two-hour observation period everyday. However, we can now choose the time frame each day, and expect the observation period to shorten over time. There’s also a measure of unpredictability. On two occasions, our daughter developed a couple hives after her prescribed dose, and we had to give her antihistamines. Other times, we had to lower her dose because she was sick, which can compromise the immune system. It is these situations, and the risk of producing a more serious adverse outcome, that discourages many allergists from taking up the practice. Indeed, OIT is still relatively controversial. Additionally, OIT treatments are still in their nascent stages and are not widely practiced, so there is less data and information available.

Importantly, not every food-allergic child or adult is a good candidate for OIT. For example, if a patient has severe environmental allergies, acute asthma, or eosinophilic esophagitis, they will not likely qualify for OIT. Additionally, OIT treatment is not available for all allergens—desensitization to peanuts, for example, is far more common practice than, say, shellfish.

If you think OIT may be of interest to your family, I’d encourage you to talk to your allergist and seek out additional information and guidance. You can also reach out to me at mnohe@allergyamulet.com for more on the parent perspective—I’m always up for a good food allergy chat!

- Meg, Director of Strategic Development

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