Should the FDA add sesame to the current list of food allergens?

biscuit-biscuits-close-up-71126Different opinions exist about adding sesame to the FDA food allergen list – we of course respect this – below is a summary of the prevalence of sesame allergy:

Only one study world-wide reported on challenge-proven sesame allergy. This is the Food Allergy and Intolerance Research Study (FAIR) from the Isle of Wight.

The FAIR Isle of Wight study involved four different cohorts:

  • a birth cohort born between 2001 and 2002 and assessed at 3 years and 10 years
  • a school cohort born between 1997 and 1998 and assessed at 6 years
  • a school cohort born between 1991 and 1992 and assessed at 11 years
  • a school cohort born between 1987 and 1988 and assessed at 15 years

Diagnosis in the FAIR Study was based on food challenge or a good clinical history plus a positive skin prick test (SPT). We published 4 relevant papers from this study, three of which included data on sesame prevalence. These are summarized in the table below.

Additional unpublished data on sesame prevalence from the fourth study covering the 1991-1992 and 1987-1988 school cohorts are also included in the table, denoted with an asterisk.

It is important to take into account that some children declined to undergo food challenges in these studies. Recruitment and retention rates (indicated in the table by % of cohort assessed) were much higher in the birth cohort at both 3 and 10 year of age than in the school cohorts.

Cohort Age assessed % of cohort assessed Food challenge/good clinical history with positive SPT (%) Reported prevalence (%) by Gupta et al. (2018) **
Birth cohort (born 2001-2002) 3 years 91.6 0.6 (5/891)1 0.22
Birth cohort (born 2001-2002) 10 years 85.3 0.73 (6/872)3 0.32
Cross-sectional school cohort  (born 1997 – 1998) 6 years 55.4 0.1% (1/798)4 0.32
Cross-sectional school cohort (born 1991-1992 ) 11 years 47.4 0% (0/775) – confirmed by a history of regular consumption or negative oral food challenges*5 0.12
Cross-sectional school cohort (born 1987-1988) 15 years 50.2 0% (0/757) – confirmed by a history of regular consumption or negative oral food challenges*5 0.12

Birth cohort (born 2001-2002) 10 years 85.3
*not in paper – taken from our unpublished data

** listed as a comparison to the Isle of Wight data despite clear descepancy in study designs.

Differences in prevalence of sesame allergy:

From this one study conducted on the Isle of Wight (UK) more than 17 years ago, it seems the reported prevalence for sesame allergy was higher in the younger cohort (0.7% for children born 2001 – 2002) than in the older cohort (0% for children born 1987 – 1988/1991-1992). This could indicate that sesame allergy prevalence might have increased. However, issues with recruitment and retention in the school cohort studies should also be taken into account  and could serve as another possible explanation for the difference in challenge-proven sesame allergy prevalence between cohorts.

The figures from the FAIR Isle of Wight school cohorts are also lower than the recent US prevalence estimates reported by Gupta et al. (2018).2Again, issues with recruitment for the school cohorts,  indicated in the table, should be taken into account. The sesame prevalence data from the FAIR birth cohort (2001-2002), are more recent and have higher recruitment/retention rates. This cohort reflects a 0.6 percent prevalence at 3 years and 0.7 percent prevalence at 10 years, both higher than the US prevalence estimates reported by Gupta et al.2

Carina Venter and Tara Dean

1. Venter C, Pereira B, Voigt K, et al. Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life. Allergy2008;63(3):354-9. doi: 10.1111/j.1398-9995.2007.01570.x

2. Gupta RS, Warren CM, Smith BM, et al. The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States.Pediatrics2018;142(6) doi: 10.1542/peds.2018-1235 [published Online First: 2018/11/21]

3. Venter C, Patil V, Grundy J, et al. Prevalence and cumulative incidence of food hypersensitivity in the first ten years of life. Pediatr Allergy Immunol2016 doi: 10.1111/pai.12564

4. Venter C, Pereira B, Grundy J, et al. Prevalence of sensitization reported and objectively assessed food hypersensitivity amongst six-year-old children: a population-based study. Pediatr Allergy Immunol2006;17(5):356-63. doi: 10.1111/j.1399-3038.2006.00428.x [published Online First: 2006/07/19]

5. Pereira B, Venter C, Grundy J, et al. Prevalence of sensitization to food allergens, reported adverse reaction to foods, food avoidance, and food hypersensitivity among teenagers. J Allergy Clin Immunol2005;116(4):884-92. doi: 10.1016/j.jaci.2005.05.047 [published Online First: 2005/10/08]

 

Travelling while following a six food exclusion diet…

During the time that I followed the six food exclusion diet, I also attended conferences, which included travelling in the US and Europe. It was not easy but totally doable.

 

Breakfast

American hotels

Breakfasts mainly consisted of oatmeal made with water, fruit/fruit salad and a suitable yogurt, which I packed in my checked bag. (Daiya Dairy-Free yogurts®, Living Harvest® Tempt Hemp Yogurt®). I never traveled without high protein, high fiber cereal bars (recipe) – these came in handy in one of the hotels where the oatmeal was prepared with milk.

One of the hardest things for me while following this diet was having to drink tea (thanks to living for almost 20 years in the UK) or coffee without a milk replacement. In the US however, many hotels have a Starbucks® in the foyer. I used to grab a coconut milk latte/cappuccino on my way to the breakfast room.

European hotels

Eating breakfast in European hotels was an interesting experience, which was easier in some hotels than others: Suitable foods included: fruit, “rice porridge” bacon, ham (of which I checked the ingredients), grilled tomato and steamed vegetables. I also prepacked suitable cereals in small containers (Arrowhead Mills® Puffed Rice, General Mills Corn ChexTM, Arrowhead Mills® Quinoa Rice) and travelled with ready-made high protein milk replacements from Orgain®.

For children I suggest to travel with a suitable high protein drink e.g. Orgain®., suitable sunflower seed butter or other suitable spreads (Sunbutter, Trader Joe’s Sunflower Butter, Harvestbetter Multigrain Spread, Once Again™ Tahini Spread) and crackers (Edward&Sons Brown Rice Snaps®, GimMe™ Seaweed Rice Chips , Goldbaum’s Quinoa Crisps and suitable corn chips). Fruit from the hotel should be suitable.

Lunch

American hotels and European hotels

Both the American and European hotels served green salads but I had to ask for a salad without any dressing on a number of occasions. I took suitable mayonnaise (NuCo Coconut Vegan Mayo®) with me when travelling but I preferred the olive oil and vinegar mix as a salad dressing.

Potato or rice were served at most meals and the hotels were happy to prepare chicken, beef or lamb without any sauces/gravies. Lunch mainly consistent of meat (of some form), salad (or steamed vegetables if available) and rice or potatoes (without any additions if available).

For children: Ask if they have carrot sticks, cherry tomatoes, slides cucumber or sweet corn as most young children, do not enjoy adult style salads. Fries may be an option if they use suitable oil and do not fry foods, other than the potato, in the same oil. In one of the hotels they offered to prepare rice noodles (Lundberg Brown Rice Pasta ®) that I took with me, covered it in a homemade tomato jus – most children should be happy with this option as well.

Dinner

American and European restaurants

Dinners in restaurants were very simple. I asked the chef to clean the grill as well as possible* or to cook chicken or beef in foil. I had a jacked potato on most occasions (without butter) with a fresh salad drizzled with olive oil and vinegar.

For children, I suggest the same strategy as lunchtime. My own experience, having traveled with my children from a young age, through many countries, is that dinner is not usually a good time for negotiations about food. Offering a high protein drink with a few bits of chopped vegetables and fruit may just save the day when dealing with a tired child.

 In flight

Flights were tricky and as the diet is so complex, I decided to take my own food. I packed a high protein powder from Orgain®, which I mixed with water on the airplane (the ready-made versions were not allowed through customs). I also took my own fruit and high protein cereal bars.

For children, and as a treat, melt some dark chocolate morsels from Enjoy life® on the high protein cereals bars. For a savory option and if the flight is not too long, take home-made hummus, home-made corn chips or try hard corn taco shells from California Tortilla®. Plain or ready salted chips and suitable cheese slices (e.g. Daiya cheese slices) (if allowed on the airplane) may be an option as well. The grab and go packs from Enjoy life foods saved me many times.

*the degree of restriction will depend on the advice given by the physician

All products listed were checked and suitable for the six food exclusion diet at the time of posting the information. I have not received any payment/honorarium/funding from any of the companies involved.

Practical Tips for implementing a six-food elimination diet (SFED)

Following a six-food exclusion diet (SFED), which involves avoiding all foods containing the six most common food allergens in the United States, can be challenging for families to implement. It is used to treat some food allergy conditions and eosinophilic gastrointestinal conditions, such as eosinophilic esophagitis.

As a dietitian and researcher who works with patients receiving this recommended treatment, I thought it would be insightful for me to experience what our patients go through, especially as we are currently doing a clinical trial investigating diets excluding one food (avoiding milk) vs. six foods (SFED – avoiding milk, egg, wheat, soy, nuts and seafood) for six weeks.

When cooking:

 Breakfast

IMG_7527Oatmeal

I am a fan of oatmeal (make sure to use the gluten free option), served with blue berries and Daiya® milk-free yogurt on the side.

Pancakes

Some mornings, I did alternate oatmeal with pancakes baked with Bob Red Mills® 1-to-1 flour mix, which substitutes directly and in the same amount as the wheat flour for whichever recipe you are using. I replaced the milk in a standard recipe with a suitable milk replacement (Living Harvest® Tempt Hempmilk, So Delicious® Coconut Milk, Good Karma™ Flaxmilk, Suzie’s® Quinoa milk Beverage) and used VeganEgg® as the egg replacer. Sometimes, in order to increase the protein content of the pancake, I replaced the egg with mashed banana and used a high-protein milk substitute.

High-protein milk substitutes

One of the few high-protein milk substitutes that I found that is free from all the allergens, including no mention of “may contain statements”, is the Orgain® range of products. I have successfully used these to make pancakes, cereal bars, high-protein milk shakes, cappuccinos, and lattes. They come in different flavors and also taste fine by themselves. It is an easy way to start the day whether you are dealing with a fussy eater or a child with food aversions.

 Lunch

Salads

I love salads and baked potatoes, but a balance of protein, carbohydrates, and fat is important for a healthy diet. Extra care is needed to make a SFED or any restricted diet a balanced diet. Sometimes I added rice or quinoa to the salad rather than eating the potato to get my carbohydrates. For protein, I usually added chicken or strips of steak. Ham or turkey slices are also an option for those who like them. Another quick but filling lunch was rice crackers with a salad and avocado.

I can suggest two different types of salad dressings:

  • mixing olive oil and vinegar
  • diluting Just Mayo® with a bit of water

Sandwiches

I am not much of a bread eater, but I did miss eating a sandwich! To solve this problem, I used Bob Redmills® bread mix and added the VeganEgg® to make SFED-friendly bread to use for sandwiches.

Dinners
Mexican

While following the SFED, I prepared Mexican meals often, using steak/chicken strips, corn tortillas, guacamole, and tomato/onion sauce, because it had a good balance of nutrients while still being flavorful.

Spaghetti bolognaise

My children adore spaghetti bolognaise. Preparing this dish with a wheat-free pasta and homemade tomato sauce allowed me to only have to make one meal – a huge bonus!
Staple meals
You could also prepare simple meals consisting of beef or chicken, rice or quinoa pasta or potato, and a salad and/or vegetable.

Personal Meal Substitution for a non-SFED Meal

Having a planned stand-by is incredibly helpful. When the rest of my family wanted to eat something that was difficult to substitute with all the necessary ingredients or when they were eating fish, I usually melted a suitable dairy-free cheese (Daiya® Provolone cheese) over corn tortillas and added a fresh green salad.

 Snacks on-the-go:

I often packed leftover quinoa pasta or rice pasta from the night before with a tomato-based sauce. I used nutritional yeast as a replacement for parmesan cheese on occasion. However, hummus (see recipe) with some vegetable sticks was my saving grace. I also often ate sunbutter as a dip for wheat-free cereal fingers (see recipe – a cereal bar cut long and slim like fingers rather than bars).CA9CA6CA-0225-458D-B353-8CC20256D3E7.jpg

 

The International Guidelines on Food Protein Induced Enterocolitis and the the driving force behind them

International Consensus Guidelines for the Diagnosis and Management of Food Protein-Induced Enterocolitis Syndrome (FPIES) were published recently in the Journal of Allergy and Clinical Immunology.

I have summarized the paper and highlighted the most important points in this blog.

As much as this paper was a mammoth task led by Anna Nowak-Wegrzyn and Matt Greenhawt, the driving force behind them was a mother, who “just wanted the best for her son”.  I am sure many of the co-authors will have interesting anecdotes of how and where they met Fallon – I for one was “recruited” as part of the iFPIES team, while  sneaking (dripping wet) late into a session on FPIES at the American Academy of Allergy, Asthma and Immunology annual meeting in Orlando 2008.

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Matt Greenhawt, Fallon Schultz, Anna Nowak, Alessandro Fiocchi

In Fallon’s words….

“The International Consensus Guidelines were truly born out of both passion and frustration. Passion to create change and eliminate the burdens faced by those affected, and frustration for the lack of clear direction and management of the disease. When my son was diagnosed six years ago, there was absolutely no information available on FPIES and this had serious implication on his quality of life and medical stability. I had to figure out how to keep him healthy, how to get him through traumatic and terrible reactions and how to feed him. I was a mother, who couldn’t feed my son. His story echoed the many families I found online, all of whom were managing FPIES on their own.

It was my dream to formalize an effective and applicable plan for every patient affected so that my son’s story was no longer the norm. One that would reflect the realities of FPIES and that would validate the symptoms and presentations us families all came to identify and know. When I approached the IFPIES Medical Advisory Board to take on this robust and difficult project, I knew it would take a great deal of time, patience and diligence. We were up against very little information and support in the medical community and often times, disbelief about the validity of this disorder. I felt a strong sense of responsibility to urgently advocate for our community and to ensure that future patients and families would never experience what those of us in the dark ages did. Each contributor was hand-selected for their expertise and more importantly, for their passion to create better pathways for their patients. They are a sincere, vocal and authentic group, all displaying compassion and empathy for their patients and practice.  I was touched by the heartfelt passion and mutual respect that these providers exhibited in each and every one of our meetings. I learned that it was not only the patients who were struggling with this bizarre food allergy, but the providers who were in the trenches, looking for answers and support for their patients. We learned from one another. It was a beautiful, collective, multi-cultural experience. In discussing the presentation in each cohort, we got clues about FPIES, we learned about different phenotypes and we took this information to create a 97 page document, marked forever in history as a jumping point for all those who have suffered the FPIES mystery.

I feel very blessed to have been any part of this monumental experience, to leave behind a legacy for future patients and providers and to lay groundwork in this disease. It is my great hope that patients and providers, worldwide, will benefit from this document and that we can take a giant leap forward to ensure a better quality of life and improved outcomes for all effected. It has been my honor to serve the FPIES community and to support the exceptional providers throughout this project.”

The International Food Protein Induced Enterocolitis Guidelines (FPIES) are out: what do they say?

 

 

Common myths regarding food allergy

I recently did a blog on common myths regarding food allergy with Dr David Fleischer, featured on the Asthma Allergies Children website.

 

Food Allergy Urban Myths: Two Experts Separate Fiction from Fact

Thanks to those that have helped to put our list together: Marion Groetch (USA), Berber Vlieg-Boerstra (The Netherlands), Rosan Meyer (France), Hannah Hunter (UK), Lianne Reeves (UK), Marianne Williams (UK), Paul Turner (UK), Isabel Skypala (UK), Fallon Schultz (USA), Raquel Durban (USA)

Weaning beyond peanut – part 2

Carina Venter and Rosan Meyer

Weaning: Points to take into account when introducing other allergens
allergens

This is a tricky topic. There are currently no specific guidelines on the introduction of allergens other than peanut. We base the following information on our own clinical experience; taking into account the NIAID guidelines. In order to explain introduction of the other allergens, let us revisit the groups identified by the NIAID guidelines:

Group 1: Infants with severe eczema, egg allergy or both.

Group 2: Infants with mild to moderate eczema.

Group 3: Infants with no eczema or food allergies

WE NEED TO EMPHASISE:

If your baby or child has any other type of food allergy other than peanut and egg, we suggest you consult your doctor before weaning onto other allergens/foods.

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Further reading: ASCIA guidelines for infant feeding and allergy prevention and EAACI food allergy and anaphylaxis guidelines: Primary prevention of food allergy