Epidemiology of food allergy

doi:10.1016/j.jaci.2010.11.044

Journal of Allergy and Clinical Immunology

Volume 127, Issue 3, March 2011, Pages 594-602

https://doi.org/10.1016/j.jaci.2010.11.044 Get rights and content

Adverse reactions to foods can occur for a variety of reasons, but a food allergy is caused by a specific immune response. Challenges to determine the prevalence of food allergy include misclassification, biased participation, lack of simple diagnostic tests, rapid evolution of disease, large numbers of potential triggers, and varied clinical phenotypes. Nonetheless, it is clear that this is a common disorder, with studies suggesting a cumulative prevalence of 3% to 6%, representing a significant impact on quality of life and costs. The inclusion of mild reactions to fruits and vegetables could result in calculation of prevalence exceeding 10% in some regions. There are data from numerous studies to suggest an increase in prevalence, but methodologic concerns warrant caution. Prevalence varies by age, geographic location, and possibly race/ethnicity. Many childhood food allergies resolve. Population-based epidemiologic studies have generated numerous novel theories regarding risks, including modifiable factors such as components of the maternal and infant diet, obesity, and the timing of food introduction. Recent and ongoing studies provide insights on risk factors, prevalence, and natural course that may inform clinical trials to improve diagnosis, prevention, and treatment.

Section snippets

Lessons from early studies

Almost every scientific and lay article about food allergy begins with a comment about prevalence. For many years, the prevalence of adverse reactions to foods was summarized as affecting 6% to 8% of children on the basis of a study by S. Allan Bock, MD,³ a study that has accumulated over 400 citations in the scientific literature. The prevalence of food allergy in the general population was often summarized as 1% to 2% on the basis of a study by Young et al,⁴ which now has over 300 citations.

Recent meta-analyses and large scale reviews

A systematic review by RAND Corp was performed by using prespecified criteria directed toward obtaining articles on epidemiologic aspects of food allergy⁵ and resulted in the conclusion that food allergy affected from 1% to 2% up to 10% of the population.² Articles were identified from the United States and Canada (92); the UK, Australia, and New Zealand (58); Europe and Scandinavia (185); Mediterranean countries (31); Japan, Korea, and China (20); and others (34).

Prevalence of food allergy to

Recent population-based studies

A number of studies published since the time of the previously mentioned reviews6., 7. continue to provide insight on the scope of food allergies. Although they suffer from various limitations, these studies demonstrate the important public health aspects of food allergy.

The self-report, self-perceived conundrum

As pointed out in the recent large reviews, guidelines, and meta-analyses,6., 7., 26 “self-perceived” adverse reaction rates exceed rates based on OFCs. The discordance has been described in various ways. For example, the new US guidelines summarize a self-report rate of 12% to 13% compared with about 3% when testing and or DBPCOFC is performed.¹ Individual studies show stronger discrepancies when considering OFC results. For example, the landmark pediatric study by Bock³ indicates 28%

Challenges in determining prevalence of food allergy

With review of various studies, we have noted a variety of limitations in determining prevalence or incidence. Indeed, there are numerous nuances that hinder accurate assessments. The limitations include definitions of food allergy and a variety of methodologic concerns. Some of the challenges are summarized in Table I.

Is food allergy increasing in prevalence?

Consider an amusing example. In 1998, there were 20 abstracts presented at the American Academy of Allergy, Asthma & Immunology annual meeting referenced under the key word “food allergy.” In 2009, there were 201 such abstracts, a 10-fold increase. This increase may represent better indexing, a response to increasing prevalence, an increase in researchers or funding, other factors, or a combinations of reasons. It is not likely that the increase simply reflects a 10-fold increase in food

Anaphylaxis and fatalities

Determination of the prevalence of food-related anaphylaxis is hindered by definitions of diagnosis, acquisition of cases through various methodologies, and many of the limitations that affect prevalence as previously reviewed. Food generally appears to be the most common trigger of anaphylaxis in the community, and arguments have been made that anaphylaxis has increased.⁴⁶ In the United States, comparison of results of similar methodologies in a similar geographic region in Minnesota from 1983

Epidemiology: beyond prevalence

Epidemiology refers to the study of patterns of health and associated factors at the population level. A variety of population-based studies have generated new hypotheses about risk factors for to food allergy.

Future directions

Although there remains uncertainty about the exact prevalence and incidence of food allergies, it is clear that the disease is common and impactful and likely has increased in prevalence similar to other atopic diseases. A summary of prevalence based on studies highlighted in this review is shown in Table III. Large-scale studies have also disclosed that the rate of allergy varies geographically, likely primarily on the basis of various environmental/dietary factors. Knowledge about the most

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Cited by (579)

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update – XII – Recommendations on milk formula supplements with and without probiotics for infants and toddlers with CMA
2024, World Allergy Organization Journal
Cow's milk allergy (CMA) is the most common food allergy in infants. The replacement with specialized formulas is an established clinical approach to ensure adequate growth and minimize the risk of severe allergic reactions when breastfeeding is not possible. Still, given the availability of multiple options, such as extensively hydrolyzed cow's milk protein formula (eHF-CM), amino acid formula (AAF), hydrolyzed rice formula (HRF) and soy formulas (SF), there is some uncertainty as to the most suitable choice with respect to health outcomes. Furthermore, the addition of probiotics to a formula has been proposed as a potential approach to maximize benefit.
These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of milk specialized formulas, with and without probiotics, for individuals with CMA.
WAO formed a multidisciplinary guideline panel balanced to include the views of all stakeholders and to minimize potential biases from competing interests. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to review by stakeholders.
After reviewing the summarized evidence and thoroughly discussing the different management options, the WAO guideline panel suggests: a) using an extensively hydrolyzed (cow's milk) formula or a hydrolyzed rice formula as the first option for managing infants with immunoglobulin E (IgE) and non-IgE-mediated CMA who are not being breastfed. An amino-acid formula or a soy formula could be regarded as second and third options respectively; b) using either a formula without a probiotic or a casein-based extensively hydrolyzed formula containing Lacticaseibacillus rhamnosus GG (LGG) for infants with either IgE or non-IgE-mediated CMA.
The issued recommendations are labeled as “conditional” following the GRADE approach due to the very low certainty about the health effects based on the available evidence.
If breastfeeding is not available, clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable consequences of each formula in infants with CMA, integrating them with the patients' and caregivers’ values and preferences, local availability, and cost, before deciding on a treatment option. We also suggest what research is needed to determine with greater certainty which formulas are likely to be the most beneficial, cost-effective, and equitable.
Influence of ingredients on the physical properties and taste of a new plant-based sweet confection being developed for individuals with food restrictions
2024, International Journal of Gastronomy and Food Science
Food restrictions faced by individuals with allergies, swallowing conditions, and food preferences, such as vegetarians and vegans, are major challenges that can affect quality of life. To overcome these food restrictions, it is necessary to create food products with appropriate physical properties using limited ingredients. In our previous study, we had shown that a sweet confection prepared from soymilk coagulated with honey had physical properties suitable for foods for individuals with swallowing difficulties. In this study, we developed sweet confections using soymilk, sugar, and glucono-δ-lactone and evaluated their physical properties. Nine trial products (TPs) were prepared with different proportions of soymilk–water, sugar–water, and soymilk–sugar and different sugar types to investigate the effect of the ingredient proportions on their physical properties. The soymilk–water ratio affected the physical properties of the TPs, whereas the other combinations did not. In addition, all TPs demonstrated physical properties that met the criteria for foods for people with swallowing difficulties, as per the Japanese Consumer Affairs Agency guidelines. When preparing TPs, we specifically considered individuals with swallowing difficulty; those with allergies to egg, wheat, or milk; and those who prefer home-prepared plant-based foods. Tasting questionnaires for TPs prepared with different sugar types were completed. The responses revealed that all sweet confections were rated delicious and that those containing unrefined sugars instead of superfine sugar resulted in a reduced sensitivity to the taste of soymilk and tofu. Sweet confections prepared with unrefined sugars could also be used as a part of a vegan diet. Furthermore, the TPs were easier to transport and were less expensive than Tofun, which was previously developed by mixing soymilk and honey. Thus, TPs can aid in expanding the food selectivity of individuals facing food and social restrictions.
Food allergy: Prevention and treatment of Cow's milk allergy
2024, Clinical Nutrition ESPEN
Outcomes and factors associated with tolerance in infants with non-IgE-mediated cow's milk allergy with gastrointestinal manifestations
2024, Jornal de Pediatria
To evaluate outcomes of oral food challenge (OFC) test to assess tolerance in infants with non-IgE-mediated cow's milk allergy (CMA) with gastrointestinal manifestations and explore clinical data predictive of these outcomes.
Single-center retrospective study including infants (age < 12 months) who were referred for CMA between 2000 and 2018 and underwent OFC on follow-up. A univariate logistic regression test was performed to evaluate variables associated with the outcomes of the follow-up OFC test.
Eighty-two patients were included, 50% were male. Eighteen patients had a positive OFC test (22%). Most patients had presented with hematochezia (77%). The median age of symptom onset was 30 days. Two-thirds of the patients were on appropriate infant formula (extensively hydrolyzed or amino acid-based formula), exclusively or in association with breastfeeding. The median time on an elimination diet before the OFC test was 8 months (Q1 6 – Q3 11 months). All cases with positive follow-up OFC tests (n = 18) had been exposed to cow's milk-based formula before the first clinical manifestation of CMA. Five out of eight cases with Food Protein-Induced Enterocolitis Syndrome (FPIES) had positive OFC tests. Exposure to cow's milk-based formula before diagnosis, a history of other food allergies, hematochezia and diarrhea were predictors of a positive OFC test.
In infants with non-IgE-mediated CMPA with gastrointestinal manifestations, the use of cow's milk-based formula, a history of other food allergies, and hematochezia and diarrhea upon initial presentation were associated factors for the later achievement of tolerance.
Adult-onset IgE-mediated cow's milk allergy—a rare phenotype
2023, Journal of Allergy and Clinical Immunology: Global
Effects of timing of complementary food introduction on childhood food allergy development: A modified role of ambient air pollution exposure
2023, Building and Environment
Food allergy increased in the recent years causing heavy disease burden worldwide, yet the unique factors for the second-wave allergy epidemic since a rise of allergic diseases are unclear.
To examine the impact of introduction timing of complementary foods on childhood food allergy and whether ambient air pollution modify this association.
A retrospective cohort study of 2,598 preschoolers was conducted at 36 kindergartens at Changsha of China during 2011–2012. A standard questionnaire was developed to survey each preschooler's introduction timing of complementary foods, food allergy, and home environments. Each subject's exposure to ambient air pollutants including PM₁₀, SO₂, and NO₂ was estimated for pregnancy and postnatal period. Association between food allergy and introduction timing of complementary foods as well as its modification by ambient pollution were evaluated by multiple logistic regression model.
Childhood total food allergy (14.6%) was significantly positively associated with early introduction to fruit or vegetable before 3 months with OR = 1.97 (1.25–3.11), especially for egg and milk allergies. Food allergy was also significantly associated with NO₂ exposure in pregnancy especially during the 1st trimester with ORs (95% CI) = 1.24 (1.00–1.54) and 1.27 (1.03–1.58) and postnatal period with OR of 1.30 (1.01–1.66) respectively for per IQR increase in their exposure. We observed that living near traffic-main road and other areas significantly increased food allergy risk of early introduction of fruit and vegetable. We further detected that early introduction of milk powder or porridge significantly decreased the risk of food allergy at the condition of light outdoor air pollution exposure during postnatal period. Sensitivity analysis showed that children living at urban area, male sex, younger age, and having breast-feeding were more susceptible to the effect of early introduction of fruit and vegetable on food allergy.
Our study indicates that the role of introduction timing of complementary foods on food allergy could be adjusted by air pollution exposure level, which may partly explain the second-wave allergy epidemic and provide a potential preventive strategy.

View all citing articles on Scopus

: Disclosure of potential conflict of interest: S. H. Sicherer is a consultant for the Food Allergy Initiative and receives research support from the National Institute of Allergy and Infectious Diseases–NIH.

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Special section: Food allergyEpidemiology of food allergy

Section snippets

Lessons from early studies

Recent meta-analyses and large scale reviews

Recent population-based studies

The self-report, self-perceived conundrum

Challenges in determining prevalence of food allergy

Is food allergy increasing in prevalence?

Anaphylaxis and fatalities

Epidemiology: beyond prevalence

Future directions

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Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Guidelines for the diagnosis and management of food allergy in the United States; report of the NIAID-sponsored Expert Panel

J Allergy Clin Immunol

Diagnosing and managing common food allergies: a systematic review

JAMA

Special section: Food allergy
Epidemiology of food allergy