Audit of manufactured products: use of allergen advisory labels and identification of labeling ambiguities

Time to ACT-UP: Update on precautionary allergen labelling (PAL)

Background

Precautionary Allergen ("may contain") Labelling (PAL) is used by industry to communicate potential risk to food-allergic individuals posed by unintended allergen presence (UAP). In 2014, the World Allergy Organization (WAO) highlighted that PAL use was increasing, but often applied inconsistently and without regulation - which reduces its usefulness to consumers with food allergy and those purchasing food for them. WAO proposed the need for a regulated, international framework to underpin application of PAL. In 2019, the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) of the United Nations convened an expert consultation to address the issue of PAL, the outputs of which are now being considered by the Codex Committee on Food Labelling (CCFL).

Objectives

To summarise the latest data to inform the application of PAL in a more systematic way, for implementation into global food standards.

Methods

A non-systematic review of issues surrounding precautionary labelling and food allergens in pre-packaged products.

Results

Approximately, 100 countries around the world have legislation on the declaration of allergenic ingredients. Just a few have legislation on UAP. Given the risks that UAP entails, non-regulated PAL creates inconvenience in real life due to its unequal, difficult interpretation by patients. The attempts made so far to rationalize PAL present lights and shadows.

Conclusions

At a time when CCFL is considering the results of the FAO/WHO Expert Consultation 2020-2023, we summarise the prospects to develop an effective and homogeneous legislation at a global level, and the areas of uncertainty that might hinder international agreement on a regulated framework for PAL of food allergens.

Simulated use of thresholds for precautionary allergen labeling: Impact on prevalence and risk

Heterogeneity and overuse of precautionary allergen labelling (PAL) in prepackaged foods have eroded its risk communication efficacy. Experts recommend applying PAL based on allergen concentration thresholds, but adoption remains limited. The aim of this study was to quantitatively assess the potential impact of this approach using Monte Carlo risk simulations. Four allergens and 9 food categories were considered in 2 scenarios: (1) consumption of products currently carrying PAL in Canada where individuals with food allergy (FA) are assumed to consume them, and (2) consumption of products without PAL, in a hypothetical context where PAL is applied based on thresholds that would protect 99 % (ED01) and 95 % (ED05) of individuals with FA, and individuals with FA systematically avoid products with PAL. In scenario (1), although several cases studied would cause <10 reactions/10 000 eating occasions (e.o.), there were also many that would cause >20 reactions/10 000 e.o. Cross-contact milk posed the highest risk (max. 1120 reactions/10 000 e.o.), and peanut, the least (max. 10 reactions/10 000 e.o.). In scenario (2), consumption of products without PAL, when using thresholds for PAL based on ED01, could lead to a maximum of 15 reactions/10 000 e. o. for all studied cases, and based on ED05, to 57 (if excluding dark chocolate with milk PAL). In most cases, the estimated number of reactions per 10 000 e.o. attributed to products with PAL currently on the market would be higher (p < 0.05) than that attributed to products without PAL, if PAL is applied based on the simulated thresholds. Thus, a threshold driven approach to adopt PAL on prepackaged foods, while advising consumers to avoid these products, could be beneficial for individuals with FA in Canada, as products without PAL would result in very few and generally mild adverse reactions.

Utility of food allergy thresholds

Food allergy is a prevalent disease worldwide that is a significant quality-of-life burden, and accidental exposures to food allergens may elicit severe, life-threatening reactions such as anaphylaxis. The threshold level, or the dose that triggers an allergic reaction determined by oral food challenges, varies considerably among individuals suffering from food allergies. Moreover, IgE concentration, diversity, or function can only partially explain this variation in threshold; pathogenic effector TH2 cells have also been found to contribute to the eliciting dose. Though very sensitive to cofactors such as physical activity/stress, the threshold is a stable and reproducible feature of an individual's allergy over periods of many months, made clear in the past several years from treatment studies in which repeated threshold determination has been used as a treatment outcome; however, there also seem to be age-related changes at a population level. More routine determination of food allergy thresholds may help patients stratify risk to improve the management of their food allergy. Precautionary allergen labeling, such as "may contain" labels, often causes confusion since they are inconsistent and regularly contain little to trace allergen residues; thus, food products with such labeling may be unnecessarily avoided. Population-based eliciting dose levels have been determined in the literature; patients at lower risk with higher thresholds may be more confident with introducing foods with precautionary allergen labels. Understanding a patient's threshold level could aid in shared decision-making to determine the most suitable treatment options for patients, including the starting dose for oral immunotherapy and/or the use of biologics.

Precautionary Allergen Labeling: Avoidance for All?

PURPOSE OF REVIEW

Precautionary allergen labeling (PAL) suggests the risk of unintended allergen presence (UAP) in food but is unregulated in most countries and inconsistently applied by food manufacturers. This review evaluates the current use of PAL, its relevance to allergic consumers, and weighs possible advantages and disadvantages of avoiding products with PAL.

RECENT FINDINGS

In most countries, manufacturers are free to decide whether, when, and how to apply PAL resulting in inconsistencies and consumer confusion. Patients with food allergy often interpret PAL incorrectly and without guidance from their health care providers. Health care providers are also prone to misinterpreting PAL, indicating a need for better education. Consumers desire guidance on whether to avoid products with PAL or not. Until further regulatory guidance is available, shared decision-making between patient and provider is required to offer individualized, rather than one-size-fits-all, approaches to PAL.

Accidental allergic reactions to food in adolescents and adults: An overview of the factors involved and implications for prevention

Accidental allergic reactions to food are one of the major problems in adult patients diagnosed with food allergy. Such reactions occur frequently, are often severe and are associated with higher medical and non-medical costs. The aim of this Perspective is to provide insight into the different factors involved in the occurrence of accidental allergic reactions and to present an overview of practical implications for effective preventive measures. Several factors affect the occurrence of accidental reactions. These factors are related to the patient, health care, or food. The most important patient-related factors are age, social barriers to disclosing their allergy and non-adherence to the elimination diet. With regards to healthcare, the degree to which clinical practice is tailored to the individual patient is an important factor. The major food-related factor is the absence of adequate precautionary allergen labeling (PAL) guidelines. Since many factors are involved in accidental allergic reactions, different preventive strategies are needed. It is highly recommended that health care be tailored to the individual patient, with regard to education about the elimination diet, support on behavioral and psychosocial aspects, usage of shared decision-making and taking into account health literacy. In addition, it is crucial that steps are taken to improve policies and guidelines for PAL.

Precautionary Allergen Labeling: What Advice Is Available for Health Care Professionals, Allergists, and Allergic Consumers?

In most countries, the use of precautionary allergen labeling (PAL) is not governed by regulation. PAL was initially identified as a judicious risk management measure to address instances of "unavoidable" cross-contact with priority food allergens during food processing. However, PAL has gradually been devalued in part due to overuse and inconsistent application by the food industry. Currently, most food products do not contain detectable allergen residue or contain only low concentrations of residue of the allergens declared using PAL; however, occasionally, high concentrations of allergen residue are reported, rendering it an ineffective risk communication tool for allergic consumers. In this context, several reasons exist that make the consumption of products bearing a PAL statement not advisable for people with food allergies. The main reason is that the risk is generally not correlated with the statement used by manufacturers. Because of the increased use of PAL on prepackaged food products, and to maximize food choices for allergic individuals, health care professionals increasingly advise some patients considered to be "not highly allergic" to consume products bearing a PAL statement. This article explains why the consumption of products with PAL is not advisable without having a full clinical evaluation and knowledge that an allergen risk assessment has been conducted. It also discusses the perspectives for a better use of PAL on the basis of the recent Food and Agricultural Organization/World Health Organization recommendations on food allergens.

Accidental Reactions to Foods: Frequency, Causes, and Severity

Purpose of Review

In this review, we present the epidemiology of food allergy and allergic reactions to foods using studies that have been published over the past decade. We review these allergic reactions — how they differ by food trigger, geographic region, demographic distribution, setting, and severity.

Recent Findings

The rising prevalence of food allergy and persistent accidental allergic reactions to foods in various settings remains a worldwide concern. Differences in global prevalence, food triggers for reactions, and severity of accidental reactions may be explained by diversity in diets and food labeling legislation. A number of studies are highlighted that describe the unique challenges and risk factors that contribute to accidental reactions in restaurants and schools, as well as the efforts that have been made to improve safety and outcomes in these settings.

Summary

Food allergy prevalence has demonstrated significant variations between regions and age groups. Despite best efforts by individuals, physicians, and legislative bodies to improve safety for food allergic individuals, accidental reactions to foods still occur and can result in fatalities.

Labeling food allergens in the packaged food pyramid groups in Brazil: analysis of descriptions, ambiguities, and risks

OBJECTIVE

The aim of this study was to evaluate allergenic labeling components of packaged foods for "What is the quality of food labels?" and "What is the group of Brazilian Food Pyramid that 'May contain' is predominant?."

METHODS

The photographs of 916 products were obtained, of which 518 were analyzed. Data from each label were evaluated according to Brazilian Food Pyramid Groups (i.e., Cereals, Fruits, & Vegetables; Soybean & products; Milk & dairy products; Meat & eggs; Fats & oils; and Sugars & sweets). Ten items were analyzed in each label, namely, the presence of a list of ingredients, alert phrase for allergy sufferers, grouping of the alert phrase, phrase location, uppercase phrase, the phrase in bold, the color of alert phrase contrasting to the background, adequate font size, do not claim the absence for any allergen with the ingredients, and others factors that make it difficult to read. For the second question, a structured questionnaire was completed, and products were classified into two categories, namely, "Contain" and "May contain."

RESULTS

The quality of the label was appropriate, and 69% of packaged foods had at least one allergen. The information "May contain" were higher in cow's milk (Cereals and Meat & eggs), soy (Soybean & products), and egg protein (Cereals). Soybean & products were the highest insecurity group.

CONCLUSIONS

Brazilian health professionals can count on good-quality labeling of packaged products. Consequently, they could promote patients' and parents/caregivers' education to consult the labels and manage the risks in processed foods about precautionary allergen labeling. Soybean & products were the most significant insecurity for food choices between Brazilian Pyramid Groups.

Immunotherapy Effectiveness in Treating Peanut Hypersensitivity: A Systemic Review

Peanut hypersensitivity is one of the top causes of food-related allergic responses and death in high-income countries. As a result, the goal of this study was to see if various forms of immunotherapies can help reduce the severity of peanut hypersensitivity reactions.

From 2019 to 2021, a systematic search of PubMed, Web of Science, Wiley online library, and Science Direct was done. Peanut immunotherapy (PIT) clinical trials were considered. There were 19 trials with a total of 1565 participants. Twelve were on oral immunotherapy (OIT), two on sublingual immunotherapy (SLIT), two on subcutaneous immunotherapy (SCIT), two on epicutaneous immunotherapy (EPIT), and one was a comparison of SLIT and OIT.

Desensitization was achieved by 74.3% of those who received OIT, 11% of those who received SLIT, 61% of those who received SCIT, and 49% of those who received EPIT. The majority of adverse events (AE) were mild to moderate. Those requiring epinephrine, on the other hand, were moderate to severe and were more common in the therapy groups.

This systematic review showed that the current PIT regimens can accomplish desensitization regardless of the route of administration, with an acceptable safety profile.

Rotulagem de alérgenos alimentares em alimentos embalados segundo grupos alimentares da pirâmide brasileira: análise da descrição, riscos e ambiguidades

RESUMO Objetivo: Avaliar os componentes alergênicos da rotulagem de alimentos embalados e responder “Qual é a qualidade da rotulagem?” e “Qual é o grupo de alimentos em que a expressão ‘Pode conter’ é predominante?”. Métodos: Foram obtidas fotografias de 916 produtos, dos quais 518 foram analisados. Os dados dos rótulos foram avaliados de acordo com os grupos da pirâmide alimentar brasileira (Cereais, Frutas & Vegetais; Soja & Derivados; Leite & Laticínios; Carne & Ovos; Gorduras & Óleos; Açúcares & Doces). Dez itens foram analisados nos rótulos: presença de lista de ingredientes; frase de alerta para alérgicos; frase de alerta; local da frase; frase em letras maiúsculas; frase em negrito; a cor da frase de alerta contrastando com o fundo; tamanho de fonte adequado; não alegar ausência de qualquer alérgeno; outros fatores de difícil leitura. Para a segunda questão, foi respondido questionário estruturado, e os produtos classificados em categorias: “Contém” e “Pode conter”. Resultados: A qualidade do rótulo foi adequada e 69% dos alimentos embalados continham pelo menos um alérgeno. A informação “Pode conter” foi mais identificada em: proteína do leite (Cereais e Carnes e ovos), soja (Soja & derivados) e proteína do ovo (Cereais). Soja e derivados foi o grupo alimentar de maior insegurança. Conclusões: Profissionais de saúde podem contar com rotulagem de boa qualidade dos produtos embalados e, consequentemente, promover a educação de pais/cuidadores para consultar os rótulos e gerenciar os riscos em alimentos processados. Soja e produtos são os alimentos com maior insegurança entre os Grupos da Pirâmide Brasileira.

Diagnosis and Management of Food Allergy

Food allergy is an immune-mediated disease and must be differentiated from other adverse effects related to food that are non-immune mediated. Symptoms of immunoglobulin (Ig) E-mediated allergy can range from mild to severe, and life-threatening anaphylaxis may occur. Current recommended strategies for diagnosis include the use of skin prick tests, allergen-specific serum IgE, and/or oral food challenges. Management entails allergen avoidance and appropriate treatment of allergic reactions should accidental ingestions occur. Treatment approaches under investigation include immunotherapy as well as biologics and novel vaccines. Attention has also recently focused on implementing strategies for prevention of food allergy.

The global burden of illness of peanut allergy: A comprehensive literature review

Peanut allergy (PA) currently affects approximately 2% of the general population of Western nations and may be increasing in prevalence. Patients with PA and their families/caregivers bear a considerable burden of self‐management to avoid accidental peanut exposure and to administer emergency medication (adrenaline) if needed. Compared with other food allergies, PA is associated with higher rates of accidental exposure, severe reactions and potentially fatal anaphylaxis. Approximately 7%–14% of patients with PA experience accidental peanut exposure annually, and one‐third to one‐half may experience anaphylaxis, although fatalities are rare. These risks impose considerably high healthcare utilization and economic costs for patients with PA and restrictions on daily activities. Measures to accommodate patients with PA are often inadequate, with inconsistent standards for food labelling and inadequate safety policies in public establishments such as restaurants and schools. Children with PA are often bullied, resulting in sadness, humiliation and anxiety. These factors cumulatively contribute to significantly reduced health‐related quality of life for patients with PA and families/caregivers. Such factors also provide essential context for risk/benefit assessments of new PA therapies. This narrative review comprehensively assessed the various factors comprising the burden of PA.

Probabilistic risk assessment for milk in dark chocolate, cookies and other baked goods with PAL sold in Canada

The risk of having an allergic reaction in milk-allergic individuals consuming products with precautionary allergen labelling (PAL) for milk has been rarely studied in products such as dark chocolate, cookies, and other baked goods. A probabilistic risk assessment model was developed to estimate potential risks. Milk occurrence and contamination levels were reported in a previous article from our group. Dose-response curves for milk were constructed using values (n = 1078) from published double-blind placebo-controlled food challenges. Canadian consumption data was extracted from a national survey, and a homemade survey involving food-allergic Canadians. Milk eliciting doses (ED) were 0.23 (ED₀₁), 1.34 (ED₀₅), 3.42 (ED₁₀), and 16.3 (ED₂₅) mg of milk protein (Log-Normal distribution). Average exposures, per eating occasion, were 24 mg (dark chocolate), 3.9 mg (baked goods), and 0.20 mg (cookies) of milk proteins. The estimated risk of having a milk-induced allergic reaction by consuming foods with PAL for milk was higher for dark chocolate (16%; 15,881/100,000) than baked goods (3.8%; 3802/100,000) or cookies (0.6%; 646/100,000) in milk-allergic Canadians. Dark chocolate, cookies, and baked goods with PAL for milk, should be avoided by milk-allergic Canadians (consuming or not products with PAL) to prevent allergic reactions.

Occurrence of milk and egg allergens in foodstuffs in Canada

Food allergies are life-threatening conditions that allergic individuals can avoid by consulting the food labels before consuming. Precautionary allergen labelling (or PAL), to warn against possible allergen cross-contamination, is widely used by food industries, reducing the food choices for allergic individuals. In Canada, there is limited information on the actual occurrence of allergens in products with a PAL related to the given allergen. This study attempted to fill the data gap by evaluating the occurrence of milk and egg allergens in Canadian products with PAL. A total of 1125 samples were analysed for milk and 840 for eggs, with 23% and 7% of these samples showing positive detection of ≥2.5 mg kg^-1 for milk and ≥0.245 mg kg^-1 for eggs. Chocolate products gave the largest number of positive results. Although the proportion of positive results was low, the levels detected reached 6471 mg kg^-1 in a chocolate sample and were indicative of possible health consequences, if PAL was ignored by allergic consumers. The occurrence data generated is destinated to be used in exposure and risk assessments, to support allergen management linked to cross-contamination, with the possible development of allergen action levels that would be used by food industries, thus improving a risk-based approach for the application of PAL.

Food Allergy: Labelling and exposure risks

In the United States, food allergen labeling is regulated by the U.S. Food and Drug Administration with the implementation of the Food Allergen Labeling and Consumer Protection Act in 2006 that requires packaged foods to clearly indicate the presence of any milk, egg, peanut, tree nuts, wheat, soybeans, fish, and crustacean shellfish. Educating patients and their families how to read food labels includes reading the ingredients list as well as the declaration statement that begins with "Contains." In addition, there is widespread use of precautionary advisory labeling, and patients should be counseled that these precautionary statements are not mandatory and not regulated and, therefore, do not necessarily identify foods with allergen contamination. An allergic reaction to undeclared food allergens as well as complacency with label reading, including precautionary advisory statements, remains a relevant risk for patients with food allergy.

Avaliação do teor de sódio em salgadinhos comerciais e da rotulagem de acordo com a RDC nº 26/2015 sobre alergênicos alimentares

Resumo Os alimentos extrusados snacks são consumidos mundialmente por causa da variedade de formas, texturas e sabores, além da praticidade no consumo. Contudo, a maioria das formulações possui valor biológico reduzido e elevados teores de cloreto de sódio (NaCl). Atualmente, no Brasil, além das informações nutricionais, é obrigatório informar ao consumidor a presença de alimentos alergênicos. Alguns requisitos sobre esse assunto foram estabelecidos pela RDC nº 26, de 2 de julho de 2015. Desde a regularização dessa resolução, existe uma falta de estudos com foco na avaliação da rotulagem de diversos alimentos, incluindo os snacks. Assim, o presente estudo teve dois objetivos: verificar os rótulos de snacks de diferentes marcas comerciais de acordo com a RDC nº 26/2015 sobre alergênicos e determinar o teor de sódio, comparando-o com a descrição na informação nutricional fornecida na embalagem dos produtos. A avaliação da rotulagem dos “snacks” extrusados encontrou inconformidades em 4 marcas das 16 analisadas. Com base na RDC nº 26/2015 sobre alergênicos alimentares, foram constatadas ausências de informações obrigatórias relacionadas a ingredientes alergênicos, como a farinha de trigo. Foi verificado que 87,5% dos snacks continham algum alergênico e que apenas 68,75% dos rótulos estavam de acordo com a RDC nº 26/2015. Além disso, foi identificado que, na maioria dos rótulos, falta a informação sobre contaminação cruzada por alergênicos no processamento dos produtos. Quanto à análise de sódio por espectrometria de absorção atômica com chama, os resultados obtidos mostraram que, na maioria das amostras, a concentração de sódio era elevada e que diferia dos valores indicados na tabela nutricional das embalagens. Portanto, a adição elevada de sódio na forma de cloreto de sódio nos “snacks” extrusados pode contribuir para exceder a ingestão diária recomendada e, consequentemente, aumentar a disponibilidade para decorrência de riscos de doenças cardiovasculares, coronárias, entre outras, associadas ao consumo de NaCl em excesso.

Diagnosis and Management of Food Allergy

Food allergy is an immune-mediated disease and must be differentiated from other adverse effects related to food that are non-immune mediated. Symptoms of immunoglobulin (Ig) E-mediated allergy can range from mild to severe, and life-threatening anaphylaxis may occur. Current recommended strategies for diagnosis include the use of skin prick tests, allergen-specific serum IgE, and/or oral food challenges. Management entails allergen avoidance and appropriate treatment of allergic reactions should accidental ingestions occur. Treatment approaches under investigation include immunotherapy as well as biologics and novel vaccines. Attention has also recently focused on implementing strategies for prevention of food allergy.

New Evaluation of Isoflavone Exposure in the French Population

The study relates the present evaluation of exposure to estrogenic isoflavones of French consumers through two approaches: (1) identification of the isoflavone sources in the French food offering, (2) a consumption-survey on premenopausal women. For the foodstuff approach 150 food-items were analysed for genistein and daidzein. Additionally, 12,707 labels of processed-foods from French supermarket websites and a restaurant-supplier website were screened, and 1616 foodstuffs of interest were retained. The sources of phytoestrogens considered were soy, pea, broad bean and lupine. A price analysis was performed. A total of 270 premenopausal women from the French metropolitan territory were interviewed for their global diet habits and soy consumption and perception. In supermarkets, there were significantly less selected foodstuffs containing soy than in restaurant (11.76% vs. 25.71%, p < 0.01). There was significantly more soy in low price-foodstuff in supermarket (p < 0.01). Isoflavone levels ranged from 81 to 123,871 µg per portion of the analyzed soy containing foodstuff. Among the women inquired 46.3% claimed to have soy regularly. Isoflavone intake >45 mg/day is associated to vegan-diet (p < 0.01). In total, 11.9% of soy-consumers had a calculated isoflavone intake >50 mg/day. This dose can lengthen the menstrual cycles. The actual exposure to phytoestrogen is likely to have an effect in a part of the French population.

How to manage food allergy in nursery or school

PURPOSE OF REVIEW

The aim of this review is to describe effective management strategies in nursery or school based upon research findings.

RECENT FINDINGS

The prevalence of food allergy and number of emergency department visits for food-related anaphylaxis are increasing in children and adolescents. As there is currently no cure, the most effective strategy to decrease allergic reactions is food allergen avoidance. However, allergic reactions are inevitable in both food allergic children as well as in first-time reactors. Misconceptions exist on the safety of products with advisory labels and questions remain on whether school-wide bans decrease the risk of allergic reactions in school. Recent legislation has prompted schools to consider requiring unassigned epinephrine autoinjectors to better manage those who have allergic reactions in nursery or school.

SUMMARY

A collective effort is required to keep children with food allergies safe at school. Families, healthcare providers, and school personnel should be informed on food allergen avoidance strategies, symptoms consistent with allergic reactions and anaphylaxis, how to respond to allergic reactions, and the impact the diagnosis of food allergy may have on quality of life for affected children and their families.

Food allergen labelling: "May contain" evidence from Malaysia

Food allergen labelling is mandatory and regulated whilst precautionary allergen labelling (PAL) remains voluntary in most countries. It is the aim of this study to identify the food allergens declared in food products sold in a developing country and to what extent food allergens and PAL are emphasised in the products. A total of 505 food and beverages (snacks, baked goods, confectionary, baby food, condiments & jams, beverages, powder & paste, instant food, chilled & frozen food and canned food) were evaluated in Malaysia. Soybean represents the largest group of food allergen declared in labels, followed by wheat and milk products. Thirteen variations of contains statement were found with "Contains [allergen(s)]" being the most common (55.02%). There were 22 different types of "may contain" statements with 'May contain traces of [allergen(s)]' being the most common advice labelling used (55.41%). Different font type or emphasis such as brackets (51.57%) and bold font (33.86%) were used to inform consumers about presence of allergens. The national regulations on food allergen labelling are then critically contrasted with other Asian countries and the EU Regulation No. 1169/2011, which represents one of the most stringent food regulations in the world. Improving current allergen labelling limitations and practices would be of great benefit to consumers to prevent risk of food hypersensitivity.

Dietary Therapy and Nutrition Management of Eosinophilic Esophagitis: A Work Group Report of the American Academy of Allergy, Asthma, and Immunology

Eosinophilic esophagitis (EoE) is a chronic/immune-antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Dietary elimination therapy has been shown to be an effective, drug-free prescription for the treatment of EoE. A range of different dietary elimination therapies have been used. Regardless of the elimination diet chosen, dietary therapy requires in-depth nutrition assessment and management. Elimination diets are not without risk and may impact nutritional status, eating pleasure, and overall quality of life. With adequate guidance, dietary therapy can be effective and nutritionally balanced, and the adverse impact on lifestyle can be minimized. This work group report addresses the potential challenges of implementing an elimination diet for the management of EoE and provides instructions and tools for physicians, dietitians, and other allied health professionals to help guide them in planning elimination diets for both children and adults.

Allergens labeling on French processed foods - an Oqali study

The French Observatory of Food Quality (Oqali) aims at collecting all nutritional data provided on labels of processed foods (nutritional information and composition), at branded products level, in order to follow nutritional labeling changes over time. This study carries out an overview of allergens labeling frequencies by distinguishing allergens used in recipes from those listed on precautionary statements, for the fourteen allergen categories for which labeling is mandatory according to European legislation. 17,309 products were collected, between 2008 and 2012, from 26 food categories. Products were classified per family and type of brand (national brands, retailer brands, entry‐level retailer brands, hard discount, and specialized retailer brands). Allergenic ingredients were identified from ingredients lists and precautionary statements. 73% of the 17,309 products studied contained at least one allergen in their ingredients list and 39% had a precautionary statement for one or more allergens. Milk (53%), gluten (41%), and egg (22%) were the most commonly used allergens in ingredients lists. For precautionary statement, nuts (20%), egg (14%), peanut (13%), soybean (12%), and milk (11%) were the most common allergens listed. Precautionary statement was most frequently found among first‐price products (hard discount and entry‐level retailer brands). National brands seemed to use it less frequently. For all these results, differences depended both on food categories and allergen categories. This study will enable to follow allergens labeling and their use as ingredients over time, particularly by assessing an hypothetical increase in allergens presence in processed food.

A Limited Survey of Dark Chocolate Bars Obtained in the United States for Undeclared Milk and Peanut Allergens

Undeclared allergens in chocolate products have been responsible for numerous allergen-related recalls in the United States. A survey was conducted to determine the prevalence of undeclared milk and peanut in 88 and 78 dark chocolate bars, respectively. Concentrations of milk (as nonfat dry milk) or peanut in three samples of each chocolate product were determined with two milk- or peanut-specific enzyme-linked immunosorbent assay kits. In 75% of the chocolate bar products with a milk advisory statement, milk concentrations were above the limit of quantitation (2.5 μg/g [ppm]), with the majority having concentrations >1,000 ppm. An additional 67% of chocolate bars with a "traces of milk" statement contained 3 to 6,700 ppm of milk. Fifteen percent of chocolates labeled dairy free or lactose free and 25% labeled vegan were positive for milk, all with concentrations >1,000 ppm. Even for chocolates with no reference to milk on the label, 33% of these products contained 60 to 3,400 ppm of milk. The survey of chocolate products for peanuts revealed that 8% of products with an advisory statement contained peanut, with the highest concentration of 550 ppm. All nine chocolates bearing the peanut-free or allergen-free statement were negative for peanut, but 17% of chocolates with no label statement for peanut were positive for peanut at concentrations of 9 to 170 ppm. Evaluation of multiple lots of four chocolate products revealed that milk was consistently present or absent for the products investigated, but mixed results were obtained when multiple lots were tested for peanut. This study indicates that a large proportion of dark chocolate bars contain undeclared milk. The type of advisory statement or the absence of a milk advisory statement on products did not predict the amount or absence of milk protein. In contrast, a lower proportion of chocolates containing undeclared peanut was found. Consumers with food allergies should be cautious when purchasing dark chocolate products, particularly those that have an advisory label statement.

Survey of undeclared egg allergen levels in the most frequently recalled food types (including products bearing precautionary labelling)

Since the number of recalls involving undeclared allergens is commonly associated with bakery and snack foods, we aimed to determine the frequency of egg allergens in a large number of these products using two commercial enzyme-linked immunosorbent assay (ELISA) methods. Samples were chosen that either had no egg identified on the product label or which had an egg precautionary statement. Among all samples, egg protein was detected in 5% of products using a Morinaga (MO) kit and 1% of products using a R-Biopharm (RB) kit. For bakery samples, egg protein was detected in 6% of 363 samples with no precautionary labelling (6% by MO and 1% by RB kit) and 12% of 80 samples which had precautionary labelling. For snack samples, egg protein was detected in 2% of 371 samples with no precautionary labelling (2% by MO and < 1% by RB kit) and 5% of 21 samples which had precautionary labelling. The disagreement rates between two methods were 5.2% for bakery products and 2.6% for snack products. The sample repeatability was at an acceptable level for bakery (< 12.5%) and snack foods (< 7.5%) for each method. The relative standard deviation between test kits was high (103.1%) for bakery foods. Four bakery products without precautionary labelling had a higher level of egg protein per serving compared with the eliciting dose (ED10 of 3.7 mg protein) for egg allergic patients. These results highlight the fact that detection methodology plays a vital role for accurate labelling control and mitigation of risk for egg allergic consumers.

Authentication of commercial candy ingredients using DNA PCR-cloning methodology

BACKGROUND

Commercial candies are consumed by all population age sectors worldwide. Methods for quality control and composition authentication are therefore needed for best compliance with consumers' preferences. In this study applications of DNA-based methodology for candy quality control have been tested. Eighteen samples of commercial candies (marshmallows, gumdrops, jelly, sherbet, gelatin-based desserts) produced by five countries were analyzed to identify the component species by polymerase chain reaction, cloning and sequencing of 16S rRNA and ribulose -1,5-diphosphate carboxylase oxygenase genes, and the species determined from BLAST comparison with universal databases and phylogenetic analysis.

RESULTS

Positive DNA extraction and amplification of the target genes were obtained for 94% of candies assayed, even those containing as little as <0.0005 ng µL(-1) DNA concentration. The results demonstrated that the species detected from DNA were compatible with the information provided on candy labels only in a few products. DNA traces of undeclared species, including fish, were found in most samples, and two products were labeled as vegetarian but contained porcine DNA.

CONCLUSION

Based on the inaccuracy found on the labels of sweets we recommend the use of DNA tests for quality control of these popular sweets. DNA tests have been useful in this field but next-generation sequencing methods could be more effective.

Clinical management of food allergy

Food allergies are commonly seen by the practitioner, and managing these patients is often challenging. Recent epidemiologic studies report that as many as 1 in 13 children in the United States may have a food allergy, which makes this an important disease process to appropriately diagnose and manage for primary care physicians and specialists alike. Having a understanding of the basic immunologic processes that underlie varying presentations of food-induced allergic diseases will guide the clinician in the initial workup. This review will cover the basic approach to understanding the immune response of an individual with food allergy after ingestion and will guide the clinician in applying appropriate testing modalities when needed by conducting food challenges if indicated and by educating the patient and his or her guardian to minimize the risk of accidental ingestion.

Frequency, severity and causes of unexpected allergic reactions to food: a systematic literature review

Food allergic patients have to deal with an avoidance diet. Confusing labelling terms or precautionary labels can result in misinterpretation and risk-taking behaviour. Even those patients that strictly adhere to their diet experience (sometimes severe) unexpected allergic reactions to food. The frequency, severity and causes of such reactions are unknown. The objective of this review was to describe the frequency, severity and causes of unexpected allergic reactions to food in food allergic patients aged > 12 years, in order to develop improved strategies to deal with their allergy. A systematic review was carried out by two researchers, in six electronic databases (CINAHL, Cochrane, EMBASE, Medline, Psychinfo and Scopus). The search was performed with keywords relating to the frequency, severity and causes of unexpected allergic reactions to food. This resulted in 24 studies which met the inclusion criteria; 18 observational and six qualitative studies. This review shows that knowledge about the frequency of unexpected reactions is limited. Peanut, nuts, egg, fruit/vegetables and milk are the main causal foods. Severe reactions and even fatalities occur. Most reactions take place at home, but a significant number also take place when eating at friends' houses or in restaurants. Labelling issues, but also attitude and risky behaviour of patients can attribute to unexpected reactions. We conclude that prospective studies are needed to get more insight in the frequency, severity, quantity of unintended allergen ingested and causes of unexpected allergic reactions to food, to be able to optimize strategies to support patients in dealing with their food allergy. Although the exact frequency is not known, unexpected reactions to food occur in a significant number of patients and can be severe. For clinical practice, this means that patient education and dietary instructions are necessary.

Precautionary allergen labelling: perspectives from key stakeholder groups

Precautionary allergen labelling (PAL) was introduced by the food industry to help manage and communicate the possibility of reaction from the unintended presence of allergens in foods. However, in its current form, PAL is counterproductive for consumers with food allergies. This review aims to summarize the perspectives of all the key stakeholders (including clinicians, patients, food industry and regulators), with the aim of defining common health protection and risk minimization goals. The lack of agreed reference doses has resulted in inconsistent application of PAL by the food industry and in levels of contamination that prompt withdrawal action by enforcement officers. So there is a poor relationship between the presence or absence of PAL and actual reaction risk. This has led to a loss of trust in PAL, reducing the ability of consumers with food allergies to make informed choices. The result has been reduced avoidance, reduced quality of life and increased risk-taking by consumers who often ignore PAL. All contributing stakeholders agree that PAL must reflect actual risk. PAL should be transparent and consistent with rules underpinning decision-making process being communicated clearly to all stakeholders. The use of PAL should indicate the possible, unintended presence of an allergen in a consumed portion of a food product at or above any proposed action level. This will require combined work by all stakeholders to ensure everyone understands the approach and its limitations. Consumers with food allergy then need to be educated to undertake individualized risk assessments in relation to any PAL present.

Unintended allergens in precautionary labelled and unlabelled products pose significant risks to UK allergic consumers

BACKGROUND

Allergens in food may pose a risk to allergic consumers. While there is EU regulation for allergens present as an ingredient, this is not the case for unintended allergen presence (UAP). Food companies use precautionary allergen labels to inform allergic individuals of a potential risk from UAPs. This study investigates the risk of an allergic reaction within the milk-, wheat-, hazelnut- and peanut-allergic populations when ingesting UK foods across multiple product categories with and without precautionary allergen labelling.

METHODS

Allergen risk assessment using probabilistic techniques enables the estimation of the residual risk after the consumption of a product that unintentionally contains an allergen.

RESULTS

Within this selection of UK products, the majority that tested positive for an allergen contained a concentration of allergen predicted to cause a reaction in >1% of the allergic population. The concentrations of allergens measured were greater than the VITAL(®) 2.0 action levels and would trigger precautionary allergen labelling. This was found for products both with and without precautionary allergen labelling.

CONCLUSIONS

The results highlight the need for the food industry and regulators to adopt a transparent, risk-based approach for the communication of the risk associated with potential cross-contact that could occur in the processing facility or production chain.

Anaphylaxis to food

This article provides a clinically focused review of food-induced anaphylaxis that includes epidemiology, risk factors, allergens, diagnosis, and management. Currently, there is no treatment for food allergy. Dietary avoidance and emergency preparedness are the cornerstones of management. Effective and safe therapies to reduce the risk of serious food-induced reactions are urgently needed, as are reliable biomarkers to predict severity.

Food allergy: a practice parameter update-2014

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology (JCAAI). The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Food Allergy: A practice parameter update-2014." This is a complete and comprehensive document at the current time. The medical environment is a changing one, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, ACAAI, and JCAAI. These parameters are not designed for use by pharmaceutical companies in drug promotion.