| Family First Feature |

Just One Bite

Food allergy diagnoses have skyrocketed over the past 20 years. Can new approaches stem the rise?

When my brother was 15 months old, my aunt presented him with what was, for him, a new food: a peanut butter sandwich. Four decades later, my mother still recalls with astonishment his reaction: He picked it up, sniffed it, and threw it across the room.

It seemed funny at the time, but as it turned out, my brother is allergic to peanuts. Not only can’t he ingest peanut butter, but a mere whiff of the stuff can trigger an allergic reaction. A taste can, chas v’shalom, be life-threatening.

“When I’m having an allergic reaction, my lips and mouth start to swell. My eyes begin to itch and become watery,” my brother describes. “When it’s a really bad reaction, I’ll get a terrible itching in my throat. It feels like it’s closing up on me, which is what’s actually happening. The airways are swelling shut.”

My brother is one of the 31 million people in America who suffer from food allergies. For these people, a small taste of everyday foods can cause mild to severe reactions that wreak havoc in their bodies.

Mild symptoms can be treated with a simple oral histamine, but severe symptoms such as anaphylaxis, a life-threatening reaction in which the airways swell shut, require immediate medical care. Each year, there are around 30,000 allergy-related emergency room visits in the United States, according to the Centers for Disease Control and Prevention (CDC).

On the Rise

During her elementary school years, Adina Stern was the lone food- allergy sufferer among her friends. When she volunteered at a day hab center during high school, however, she found a three-page list of allergic patients, ranging in age from pre-1A through eighth grade. “When I was a kid, there would have been a list with just my name or maybe one other girl on it,” says Adina, who is now in seminary.

Over the last few decades, allergies have become increasingly common. In fact, between 1997 and 2008, food allergies doubled, and tree nut allergies more than tripled in the US, according to the CDC.

“The incidence of foodborne allergies has gone up a lot, but some of it is better diagnosis,” says Dr. Marc J. Sicklick, who has four decades of experience in allergy and immunology, and maintains a private practice in Cedarhurst, New York. “When I grew up, I had one friend with food allergies. That was it. It was almost unheard of. But over the past few decades, as awareness of food allergies has increased; so have the number of evaluations. The result is that we now have more diagnoses.”

In the 1970s, during Dr. Sicklick’s medical training, patients who were brought in with anaphylaxis were often diagnosed as having been stung by a bee, although he says that “no one ever saw them being stung.” That was the diagnosis even if it was the dead of winter and there were no bees around. As allergy awareness grew, the incidence of “bee stings” dropped significantly.

Another factor contributing to higher food allergy rates is the prevalence of shaky diagnoses. “A lot of laboratories have pediatric panels, and as part of routine care, pediatricians are now checking for allergies,” says Dr. Sicklick. They typically use blood testing, which picks up free-standing antibodies against the foods, or skin testing, which shows how the body reacts to it. These tests, however, can only be considered circumstantial evidence.

“Physicians will label people with allergies because they have an antibody. But antibodies don’t prove that there’s an actual allergy,” says Dr. Sicklick. “A lot of allergies that are diagnosed aren’t clinically relevant.”

So why are lab tests done at all? Because they give allergists like Dr. Sicklick the ability to decide when it’s worthwhile to run a “challenge test,” a procedure in which food is introduced in increasing doses under medical supervision to determine if a patient can tolerate the food.

“The gold standard for diagnosing a food allergy is answering the question of whether the food can be eaten without causing a reaction. That’s really the bottom line,” says Dr. Sicklick. “Unfortunately, I see a lot of people who were diagnosed with allergies but don’t really have them.”

That was the case with Libby’s ten-year-old son Moishe.* After a skin test indicated a severe allergy to all tree nuts and peanuts, Moishe and his family were vigilant about nut consumption in the house. Then Moishe’s allergist retired. The new allergist wasn’t convinced that Moishe was allergic to every tree nut. After running a blood test and skin test, she decided to conduct a food challenge with almonds and, later, macadamia nuts. Moishe tolerated both with zero symptoms. “My kids begged me to celebrate by throwing a party with every almond dessert we could think of,” Libby says.

The Hygiene Hypothesis

Research shows that the wealthiest countries have the highest allergy rates. Experts says this may be connected to our increased focus on sanitation. As surroundings become increasingly hygienic, helpful microorganisms appear less frequently, which makes them seem foreign to our immune system — which then attacks them. This leaves us with weaker, less-developed immune systems overall. Scientists call this explanation the “hygiene hypothesis.”

“I believe that’s true,” Dr. Sicklick says. He explains that our immune system is designed to react to intruders (such as venom or parasites) with an antibody called Immunoglobin E, or IgE, which triggers the release of a compound called histamine when it identifies a threat. The symptoms of dilated blood vessels, inflamed tissue, itching, or wheezing are the body’s way of trying to remove its perceived threat.

The more the body fights off invaders — such as parasites, which are common in poorer countries — the stronger the immune system gets. Now, what happens in wealthier countries, where there’s less germ exposure? The immune system needs to be used, and if it doesn’t have real invaders to fight against, it will be used for something else — like allergies.

When a person has a food allergy, the immune system is essentially overreacting to what should be a harmless substance in the environment. The body produces a flood of IgE antibodies, which release powerful chemicals like histamines that trigger allergic symptoms in the nose, eyes, lungs, throat, or on the skin. These reactions can vary from annoying to life-threatening, the most serious of which is anaphylaxis.

Since COVID-19, our world has gotten even more sterile. Not only that, but Covid left kids locked up indoors for long periods. Because they weren’t exposed to anything, they didn’t pick up normal childhood viruses. This explains why viruses like RSV and the flu are so devastating now. After years in a sterile environment, kids are being infected, but their immune systems aren’t primed to fight back.

For this reason, Dr. Sicklick doesn’t get too nervous when a six-month-old has a cold. “RSV (a respiratory virus) is devastating, so I don’t want newborns catching a cold, but at six months and older, getting a mild infection and getting over it is good for the kid’s immune system, to program it in the right direction.”

“Being too clean is not a good thing,” agrees Dr. Richard Schwimmer, a Brooklyn-based pediatrician who has been practicing for more than five decades. “If you’re a kid, play in the dirt a little bit. Exposure to things at a low dose can be a good thing.”

Interestingly, Dr. Schwimmer hasn’t observed increased food allergy incidence in his practice. He attributes that to the fact that most of his young patients are breastfed. “Breastmilk has immunoglobulins” — also called antibodies — “and protects against a lot of problems, especially during the newborn period.” He explains that those early months of life are critical for regulating the immune system’s response to threats. This is especially important for infants who have a family history of food allergies or a risk factor for developing them, such as eczema.

Exposure Timing

It was once believed that avoiding food allergens early in life would decrease the chances of allergies. But a study called LEAP (Learning Early About Peanut Allergy), also known as the Bamba Effect Study, conducted in 2015, proved that children who were exposed to peanuts earlier in life — as most Israeli Bamba-loving children are — had a lower allergy rate.

According to USDA guidelines, “There is no evidence that delaying introduction of allergenic foods, beyond when other complementary foods are introduced, helps to prevent food allergy.”

There are studies that show that when you give peanuts to children at risk — they may have eczema, for example — in a controlled setting such as a doctor’s office, the incidence of peanut allergy that is life-threatening is significantly decreased. “For that possibility, you need to give it to them regularly — I mean really regularly,” says Dr. Sicklick.

So when should parents start exposure? “The pendulum has swung back and forth on that so many times,” says Dr. Sicklick. “The Rambam talks about the shvil hazahav, which is moderation. I’m not a fan of really early or really late exposure. When the pendulum swings back and forth, get somewhere toward the middle.”

Living with Allergies

A few years back, my brother and his family picked up some takeout for a Chol Hamoed treat. They enjoyed the food in their beautiful succah, but after just a bite, my brother said he had to leave for Minchah.

Ten minutes later, he was back.

“His face was purple,” said my sister-in-law, who immediately called Hatzalah.

It turned out that the single bite of chicken my brother had eaten had some sort of peanut sauce.

“The chicken incident was really scary because I couldn’t think straight,” my brother shares. “Hatzalah told us that every allergic incident like that cuts your time in half. If it took me ten minutes to go into anaphylactic shock last time, now it will take five.”

A famous story in the family involves his mother-in-law, who once baked a lokshen kugel with a ground nut topping so she could use up the leftover nuts from her mishloach manos. My brother, a huge fan of her cooking, helped himself to a large slice — and immediately followed with a call to Hatzalah, who brought him to the hospital. “We joke that she tried to kill me,” he quips.

Part of what makes it so hard to have a foodborne allergy is that it’s almost impossible to avoid certain foods entirely, no matter how much you try.

Manufacturers can mislabel things. Food establishments can be lax about allergen warnings or cross-contamination. My brother once had a reaction to a chocolate truffle that the store insisted was nut-free.

“Allergies are more than a sensitivity,” says Adina. “It’s a real thing that could mean life or death.” She had an elementary-school teacher who insisted that there were no allergens in a cake that caused her to have a reaction. Another quick-thinking teacher saw what was happening and gave her Benadryl. “That was almost scarier than the reaction,” she reflects. “Not being taken seriously.”

Adina says that sometimes even thinking that a food contains a trigger is enough to cause mild symptoms. “When you think you’re allergic to something, it creates a connection in the brain that can make your throat and mouth get itchy,” she explains. Sometimes, she takes Benadryl just because she’s scared, especially when a label says, “may contain.”

Managing Allergies

Antihistamines and other medications are helpful for mild reactions, but for anaphylaxis, the EpiPen, an injector that contains a drug called epinephrine, is the answer. “Benadryl helps itching but does not treat or prevent respiratory distress or blood pressure issues,” says Dr. Sicklick. “I am aware of fatalities caused by Benadryl delaying the administration of epinephrine. All my patients are instructed to give Epi first and not worry about it not being needed. Epinephrine is safe.”

Epinephrine reverses the symptoms of anaphylaxis: It opens airways in the lungs, relaxes muscles, and reverses a decrease in blood pressure. According to Dr. Sicklick, it decreases the odds of a fatality by 99 percent if injected immediately.

Epinephrin’s introduction was lifechanging. And there are strides being made with the product. “I expect to see a nasal spray of epinephrine out within a year,” says Dr. Sicklick. “The people who make the nasal spray for Narcan, which is for drug overdose, are coming out with an epinephrine spray using the same mechanism. There’s still a very real fear of needles out there, so this will be a game changer.”

Possible treatment of allergies can include desensitization — also known as oral immunotherapy treatment (OIT) — a treatment in which patients are exposed to increasing amounts of an allergen daily under medical supervision to build their resistance to that food.

In 2020, Palforzia became the first FDA-approved form of oral immunotherapy for peanut allergy sufferers between the ages of 4 and 17. The drug is administered in the form of a pill that contains small doses of peanut protein. The goal of OIT is to reduce the severity of reaction and prevent anaphylaxis; it does not cure allergies. It’s a complicated process that requires long-term commitment to daily dosing and maintenance as well as precautionary restrictions, such as avoiding any physical activity for several hours after treatment. Side effects include gastrointestinal and esophageal difficulties, and for the treatment to work, it must be lifelong.

“I personally have an issue with doing something that is still experimental for a condition that is not a progressive fatal disease,” says Dr. Sicklick. “How many times do we have things approved and then find out years later that they do damage?”

Biologics, which work by blocking the IgE hormone that causes reactions, is another experimental field. Drugs such as omalizumab, currently sold as Xolair to treat asthma, and dupilumab, sold as Dupixent for treatment of severe eczema (which Moishe is on for his eczema issues), are being tested for the treatment of food allergies. As with desensitization, the goal of biotherapy would be to mitigate reactions rather than eliminate the allergy.

As the number of foodborne allergy diagnoses continues to climb, so does awareness — and sensitivity. Airlines no longer serve peanuts. Food labels contain allergy warnings. Schools are peanut-free. We may have a way to go, but it’s a different world from the one my brother found himself in when he threw that peanut butter sandwich.

Will there ever be a cure? We don’t know the answer to that. But for now, knowledge is power.

The Ninth Allergen: Sesame Seeds

As of January 1, 2023, all food manufacturers are legally required to list sesame seeds as an allergen on packaging. As the FDA announced on its website, “Sesame joins eight other foods already declared as major food allergens by federal law… milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, and soybeans.”

“You don’t even know what this means for us,” says Libby, whose ten-year-old son is highly allergic to sesame seeds. “If a product obviously has sesame seeds — like challah or crackers — my son can avoid it. But ground sesame seeds are in more products than you realize, and you’d never know because it could be listed under ‘spices’ or ‘natural flavorings’ in the ingredient list. This law is a game changer.”

Libby adds, “You’d be surprised by how many people don’t know that tahini is made from ground sesame seeds. One morning at school, my son’s friend gave him a homemade cookie. We found out later that the entire batch had a single teaspoon of tahini in it. Within minutes of eating the cookie, my son started to feel sick: itchy throat, sneezing, watery eyes, and abdominal pain. Luckily, my son knew enough to get help immediately from the school nurse, who gave him 10ml of Benadryl to treat the symptoms.”

Looking to the Future

As research develops to determine the possible causes of food allergies, new pathways are created for breakthroughs in preventing or reducing allergies.

The role of genetics in allergies is not a simple determination, with almost 100 genes involved. But in 2017, a group of researchers from Germany and the United States tested 1,500 children and discovered five genetic risk loci for food allergies.

There may be a connection between sun exposure and allergy incidence. One study published by the National Institute of Health in 2018 found higher incidence in populations further from the equator. However, the role of Vitamin D itself remains ambiguous: A 2020 study published on the National Institute of Medicine website found that higher levels of Vitamin D increased the probability of food allergies.

Changes in gut microbiota (bacteria) are considered factors in the development of food allergies. Cathryn Nagler, an immunologist at the University of Chicago, is one researcher working with a team to develop microbiome-based treatment.


(Originally featured in Family First, Issue 837)

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