The first time Genevieve Carden tried peanut butter was very nearly her last. She was just 15 months old when her mother, on the recommendation of her pediatrician, gave her a taste —never expecting that the tiny bite of a childhood favorite would forever change how their family would go about their everyday lives. Genevieve went into such severe anaphylactic shock that she arrived at the emergency room limp, unresponsive, and so swollen that she was unrecognizable.
“We had no warning,” Genevieve’s mother, Summer Carden, recalls. “We had no experience with food allergies.” Thankfully, Genevieve, now seven, responded to an epinephrine injection administered by the hospital physicians. For the Carden family, though, nothing was ever the same.
Their story, sadly, isn’t uncommon. Approximately 32 million people in America suffer from food allergies, according to Food Allergy Research & Education (FARE), including 5.6 million children under age 18. Forty percent of those children are allergic to more than one food. At the same time, a number of other conditions that likely have a biological connection—eczema (atopic dermatitis), asthma, and hay fever (allergic rhinitis)—have increased in prevalence, too.
What’s truly mystifying, however, is how food allergies appear to have skyrocketed over the past decade. The latest numbers, based on health insurance claims, estimate that anaphylactic food reactions increased 377 percent between 2007 and 2016. In Maryland, anaphylactic food reactions increased by 114 percent during that same time period.
While some 170 foods have been reported to cause an allergic reaction, there’s eight main players responsible for most reactions: milk, eggs, peanuts, tree nuts, wheat, soy, fish, and shellfish. Additionally, sesame is an emerging concern. Lawmakers in Maryland have taken action to prevent the worst outcomes when it comes to food allergies; for example, it’s one of just 12 states that requires schools to stock epinephrine, which can help prevent fatalities in schools. “The reason these fatalities hit so hard is that they’re always preventable,” surmises Gina Clowes, national director of training and outreach for FARE. “We can go back and see the mistakes that have happened.”
The Rise of Food Allergies
The numbers don’t lie—there’s clearly a reason to be alarmed about food allergies. Of course, the most prevalent question is, “Why?” The answer to that is an ongoing topic of discussion. It’s a significant area of study for researchers, who have looked at possible links between food allergies and factors such as breastfeeding, Cesarean sections, diet during pregnancy, and vitamin D consumption without finding any definitive or specific connections.
As of now—and this is likely to change as research expands—there are two main theories as to why food allergies have become such an issue:
The Hygiene Hypothesis
Humans, particularly Americans, live in a world that has been rid of germs. Because of the raging battle against germs through hand sanitizer, antibacterial wipes, and other cleaning products, the immune system hasn’t been trained to tell the difference between harmless and harmful irritants. “We are a clean society,” says Lisa Gable, FARE CEO. “It’s in a clean society that you see [food allergies] multiply.” Could humans’ immune systems simply be getting “bored”? Well, consider this: Research finds that people who live on farms develop fewer allergies. Exposure to farm animals also exposes a person to more germs known as endotoxins, which stimulate the immune response and decrease allergic inflammation. Additionally, the prevalence of food allergies has increased mostly in urban and first-world environments compared with rural and third-world countries.
The Food Introduction Hypothesis
Over the past three decades, pediatricians told parents to postpone introducing high-risk food allergens to children until a year of age or even later. The idea behind these guidelines was well-intentioned but had no effect on rates of diagnoses. As anyone who’s had a baby in the past couple of years knows, researchers and pediatricians are beginning to throw those food introduction timelines out the window. In 2015, a landmark study, Learning Early About Peanut Allergy (LEAP), concluded that introducing peanuts to infants between four and eleven months of age—far sooner than age three, as previously recommended—dramatically decreased the likelihood of developing a peanut allergy compared with waiting until age five.
Although children are often the focus when food allergies are being discussed, more and more adults are developing food allergies after spending their adolescent years free from food allergies. “We have dietary trends that, I think, are exposing people on a more frequent basis to more types of allergens,” Gable mulls. “We’re seeing a rise in sesame allergies and asking to add it as the ninth major allergen.”
It’s no coincidence that sesame happens to be on the forefront of popular culinary trends, such as tahini—a paste made from sesame seeds that’s a major component of hummus. Additionally, more people are reaching for plant-based proteins, which contain allergens such as soy, wheat, and egg. “Everyone who is hyper-aware is recognizing the influence of food trends,” Gable says.
Life and Death in Schools
It’s difficult for parents to control what foods might get handed to their kids at school, and that can be particularly stressful if your child suffers from a food allergy. In private preschools and daycares, bans on ultra-risky foods like peanuts help give parents a sense of relief, but neither Anne Arundel County Public Schools (AACPS) nor Queen Anne’s County Public Schools (QACPS), which are managed by the foodservice company Sodexo, restrict any specific foods from entering the buildings.
That doesn’t mean that food allergies aren’t a top-of-mind concern for staff, particularly the head of the foodservice departments, who works with parents, teachers, nurses, and administrators to ensure safety for all students. Jodi Risse, who’s helmed AACPS’ Food & Nutrition Services for 25 years, notes that all the meals served in the cafeteria are peanut- and tree nut-free. As part of the operation’s bid process, vendors must send a nutrient label, ingredient list, and a statement verifying that the product is free from peanuts and tree nuts.
The precautions, of course, don’t stop there. Other ways the department helps families with food allergies include:
- Notifying cafeteria cashiers of any allergies when a student purchases food.
- A picture of the student and their specific allergy pops up at the point of sale, which allows staff to ensure none of the items being purchased will trigger a reaction.
- Providing peanut-free or allergen-free cafeteria tables
- Having Food & Nutrition Services staff regularly participate in professional training that includes education on food allergies.
- Holding monthly meetings for the district’s Wellness Council, which includes school nurses and the foodservice department.
- Listing all ingredients for every product served or recipe made in the school on the district’s website.
In addition to implementing procedures such as annual staff training and point-of-sale student identification, QACPS has made nutrition information more accessible with the Sodexo So Happy smartphone app, available for Apple and Android.
“When employees put their production sheets in, the info rolls right into the app,” says Julie Hickey, RD, a dietitian for both QACPS and Talbot County Public Schools (TCPS). “The parent can pull up what’s for breakfast and lunch at school, and it lists out the items and identifies the allergens.” As of earlier this year, the app is also compatible with the Amazon Echo, so parents and students can ask Alexa what’s on the menu and learn about the allergens.
Of course, the impetus is not entirely on cafeteria staff or the teachers. An important part of keeping students safe is the partnership between parents and staff in implementing the 504 Plan, which outlines accommodations for students with disabilities. Under the Americans with Disabilities Act (ADA) of 1990 , food allergies are considered a disability because it affects “major life activities”—e.g. eating and breathing—which means that both public and private schools must make reasonable accommodations to provide services, such as school lunch, for children with food allergies (though private religious schools are sometimes exempt).
Mom Diane Eager worked with AACPS to implement 504 Plans for both of her sons, 15-year-old Ryan, who’s allergic to egg, tree nuts, and peanuts, and 12-year-old Alex, who’s allergic to milk, egg, soy, peanuts, tree nuts, and shellfish. She’s often concerned about her kids being given food-based rewards in the classroom. “At our 504 meetings, I give articles to the teachers that provide suggestions of what to give out instead of food,” she says, also recalling that she was asked years back to speak to the PTA about food allergies.
Carden, however, decided against putting a 504 Plan in place for Genevieve, and she allows her daughter to sit at the “regular” lunch tables versus the nut-free tables. “She started school at six years, and I felt it was time she started to learn to eat safely around others, even when they were eating her allergen,” Carden says. “The nut-free table, while an option, is not realistic for teaching her to protect herself.”
As previously mentioned, Maryland is one of just 12 states that requires schools to stock epinephrine; the University of Maryland stocks it on campus, too. “In Virginia, a little girl died, and that was the impetus for schools to stock epi,” Clowes says. “That was not the case in Maryland, and it shouldn’t have to come to that.”
To Ban or Not to Ban?
If peanuts and other allergens are so deadly, particularly to unsuspecting children, should they be banned from schools? The general consensus among researchers is no. Peanut-free schools aren’t any safer for kids with allergies than those that allow the nut.
“I don’t think peanut bans are necessary,” muses Julie Hickey, RD, who has been a dietitian for 25 years and currently works with Queen Anne’s and Talbot County Public Schools. “As long as precautions are in place, the parents and students need to take responsibility. If we ban it in school, it doesn’t stop them from encountering it in other places.”
A study published in the Journal of Allergy and Clinical Immunology, which reviewed rates of epinephrine administration in K–12 schools, found that schools that were said to be peanut-free had the same rate of epinephrine administration as those without peanut policies. However, having peanut-free tables in the school cafeteria did make a difference.
Jodi Risse of Anne Arundel County Public Schools shares the same opinion as Hickey. “As our children grow and experience independence, they have to deal with it,” she says.
Making a Change
When someone’s life is so significantly impacted by food, a family member’s food allergy diagnosis can be both a shock and a substantial adjustment. Such was the case for Jeff Jacobs, owner of Carrol’s Creek Cafe in Annapolis, whose son is severely allergic to tree nuts. He knows firsthand the struggle that families that deal with food allergies face when attempting to eat at a restaurant and, because of that, the team at Carrol’s Creek began looking at whether it was feasible for the restaurant to go peanut- and tree nut-free free.
It was, as Jacobs and his staff quickly found out, entirely possible. In February, Carrol’s Creek Cafe was certified as nut-free by Kitchens with Confidence, the leading food allergen and gluten free auditor for full-service kitchens. “It’s not just ‘don’t order nuts’—that’s the easy part,” Jacobs notes. “What scared us the most was what we didn’t know.” To combat that, the restaurant hired a consulting firm to look at all the ingredients it buys, the practices of the manufacturers that the ingredients come from, and where to go when they had to find new products.
The hardest substitution to make, Jacobs recalls, was ice cream. “We used Annapolis Ice Cream and really liked having a small, craft ice cream,” he says. However, it didn’t fit the needs of the new allergen-free policy, requiring Carrol’s Creek to switch to a New York City store with ice cream that is fully nut-, peanut-, egg-, and sesame-free.
Overall, though, the process has been much easier than anticipated, and the restaurant didn’t have to raise prices to account for higher-priced ingredients, nor did the team hear any negativity from the public. “We’ve gotten amazing feedback,” Jacobs adds. “I can’t tell you how many times we’ve heard, ‘My daughter has never been to a nice restaurant before.’ It’s been great to give that to somebody.”
Maryland is one of six states that has food allergy laws in restaurants, Gable says; it requires that a poster about food allergies be prominently placed in the staff area. She also notes that the National Restaurant Association developed a ServSafe certification for restaurants that includes training on food allergies. All restaurants in the state must have a certified food service manager on the premises during all hours of operation.
“As the number [of people diagnosed] increases, there are more reactions and there are more fatalities,” Clowes says. “We don’t need to wait for fatalities for training on food allergies.”
A New Way of Life
The effect a food allergy diagnosis has can’t be overstated—not only for the patient but also for their loved ones, who are constantly on guard to ensure their safety. “I remember crying the day we found out [about Genevieve’s allergies], thinking our life would never, ever be the same again—and it hasn’t been,” recalls Carden. “From where we will be throughout the day, who will be with our daughter for each activity, who around her might have ingested peanuts or peanut butter, and where we will need to carry EpiPens for the day—this is the most important focus of our day, every day.”
On its website, (www.foodallergy.org), FARE offers the Food Allergy Field Guide for those who have been newly diagnosed with food allergies, which Clowes says is the most downloaded resource on the site. It provides information about what people need to know about food allergies, an anaphylaxis emergency care plan, food label information, advice about dining out with food allergies, and frequently asked questions.
Eager’s children are old enough to be aware of the dangers that certain foods pose to them, and they are capable of administering their own EpiPen injections. However, she says her guard never goes down because ingredients are always changing, even for non-food products, like adding tree nut oils to soaps.
“The moral of the story is be prepared—but you get caught off-guard every once in a while,” Jacobs says, recalling when they were making quesadillas with shredded cheddar cheese and happened to notice that the package said it may contain almonds. Later, he found out, the manufacturer adds nut dust to ensure the cheese doesn’t clump. What was just a regular family gathering could have turned into something much more perilous—and the panic and fear surrounding that risk is what Carden would like other people to understand.
“The fear is so extreme that it ruins what should be a happy experience, like eating out or celebrating a birthday with a slice of cake,” she says. “Knowing that for her entire life, every meal she eats and every product she tries, that she could die—it’s a heavy burden.”
