Not Only Surviving, but Thriving: A Webinar for Adults with Food Allergies

Stephanie Leonard, MD Director, Food Allergy Center University of California, San Diego Rady Children’s Hospital San Diego September 23, 2015

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Welcome to our webinar! This webinar was made possible through generous support from:

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Today’s Presenters

Stephanie Leonard, MD Director, Food Allergy Center

University of California, San Diego Rady Children’s Hospital San Diego

Today’s Presenter

Allergy versus Intolerance

§ Allergy: abnormal immune response to food protein •  IgE-mediated = immediate type, risk for anaphylaxis •  Pollen-food (oral) allergy syndrome •  Celiac disease

§ Intolerance: non-immune adverse reactions •  Lactose intolerance = metabolic •  Chemical migraine triggers (aspartame, MSG, nitrates/

nitrites, alcohol, coffee, and chocolate) •  Other chemical triggers, such as sulfites (red wine)

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Signs of Anaphylaxis

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Adult Food Allergy

§ 9 million or 3-4% of adults in the US

§ Most common: peanut, tree nuts, fish, shellfish, mollusks

§ Most develop in childhood but food allergies can develop at any age

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Study in Urban Adults

§ 85% of patients with food allergy diagnosis seen by Internal Medicine were women.

§ About 86% of adult patients with physician-documented food allergy received prescription for self-injectable epinephrine.

§ Only ~50% had their food allergy evaluated by an allergy specialist.

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Agarwal and Wang. J Allergy Clin Immunol. Vol 131(2):AB23.

Fatal Food Anaphylaxis

§ The risk of fatality for a food-allergic child is approximately 1:800,000 per year.

§ Data are lacking regarding the risk of fatal food allergic reactions in adults.

§ Adolescents and young adults are at highest risk, likely due to increased risk-taking.

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Sampson et al. J Allergy Clin Immunol. 2014 Nov;134(5):1016-25

Quality of Life

§ Compared to general population, food-allergic adults reported poorer overall health, more limitations in social activities, and less vitality.

§ Food allergic patients reported poorer health-related quality of life than patients with diabetes, but better than patients with rheumatoid arthritis, asthma and irritable bowel syndrome.

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Flokstra-de Blok BM et al. Allergy. 2010 Feb;65(2):238-44

Food Allergy and Bullying

§ 45% of children (n=251) reported bullying § Teased (42%), food waved (30%), criticized (25%),

threatened (15%) § Classmates (80%), other students (34%), teachers/staff

(11%), siblings (13%), other relatives (4%). § Associated with decreased quality of life and increased

distress in parents and children, independent of reported severity of allergy.

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Shemesh et al. Pediatrics 2013 vol. 131(1):e10-17.

Psychosocial Impact

§ Restrictions •  Social activities •  Traveling •  Careers

§ Finding support •  Online boards •  Support groups •  Counseling §  Anxiety, fears, phobias and depression

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Areas of Food Allergy Management

§ Home § Work § Dining Out § Travel § Camping and Hiking § Relationships

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Allergen in the Environment

§ General Rule: ingestion is required for a systemic reaction or anaphylaxis to occur •  Exception: aerosolization, e.g. roasting nuts, boiling

milk, steaming eggs, fish or shellfish, sifting flour •  Contact may cause superficial redness, itching or hives

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Cross contact

§ Even traces of allergen in contact with safe food can make it unsafe •  Knife with dipped in peanut butter, then dipped in jelly •  Pan used to fry fish and then cook vegetables

§ If a mistake is made it can’t be undone; the safe food needs to be prepared again from scratch •  Removing nuts from a salad •  Scraping cheese off a sandwich

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Special Environments

§ Buffets/salad bars § Ice cream shops § Bakeries § Food counters (deli, seafood)

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Grocery Shopping

§ Avoid bulk bins, food counters and food bars § Avoid foods packaged in-house without a list of

ingredients, especially if chef/food preparer is not available to answer questions

§ Keep unsafe foods separate from safe foods in the cart and when bagged

§ Read ingredients and labels EVERY time

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Best Practice in the Kitchen

§ Cooking •  Prepare safe food first •  Use dedicated safe utensils, dishes, appliances •  Use dedicated safe area in kitchen •  Serve food-allergic individual first and separately •  Avoid “make-your-own” spreads

§ Food storage •  Squeeze bottle condiments

(no double dipping) •  Label food •  Dedicated shelves for safe foods •  Keep unsafe foods below safe foods

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Best Practice When Cleaning

§ General Rule: beware of same utensils, dishes, cutting board, pots/pan, grill, fryer, steamer, etc. •  Scrub with soap and water; rinse residue off sponges/

brushes or use dedicated ones •  Dishwashers do not remove all of allergen; rinse off

residue first •  Alcohol sanitizers do not remove allergen; use wet

wipes and scrub

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Family/Friends/Coworkers

§ Issues •  They may forget •  They may want to help but not fully understand •  They may get offended when you don’t trust them

§ Tips •  Use patience and humor •  Explain your fears, anxiety, past experiences •  Give them credit for trying to accommodate you, but

don’t get into an unsafe situation because you don’t want to hurt their feelings

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Golden Rules for Managing Food Allergy

1.  Be prepared 2.  Ask questions 3.  If you are not sure, do not eat it 4.  Get involved 5.  Help others help you 6.  Make sure someone knows about your food allergy

and what to do in case of emergency

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Be Prepared

§ Pack safe snacks!! § Always carry emergency medications § Have medical alert identification on you

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Epinephrine Auto-Injectors

§ Carry two devices § Renew annually § Keep at room temperature § Call 911 after use

§ Epinephrine saves lives!!

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Work

§ Hotspots •  Shared kitchen •  Lunch meetings and celebrations •  Networking restaurant meals

§  Tips •  Bring own utensils, dishes, mugs and sponge, or use disposable •  Use secure containers in refrigerator and microwave or, if

possible, use private space and appliances •  For potlucks, set aside some of the safe food you brought •  Be social even if you can’t eat the food

§ Know your rights

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Dining Out

§ Research restaurant and menu § Call ahead and speak to chef/manager § Check-in with host/hostess § Discuss food allergy with waiter •  A good response: they make a note, check with kitchen

and get back to you to confirm your dish is safe § Confirm when your meals comes that it is safe •  Especially if waiter has not gotten back to you

§ If it doesn’t feel right, don’t eat it

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Pitfalls in Restaurants

§ Servers may not understand severity and view it as an intolerance

§ Chefs may make last minute changes or substitutions not indicated on menu

§ Staff may not realize ingredients contain allergens (i.e. butter has milk proteins)

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Fear of Missing Out

§ Friends/family may choose to go to certain restaurants or cook certain dishes when you’re not available

§ You can choose to go and socialize without eating or just have a drink

§ Gives an incentive to cook or bake •  Allergen free cookbooks •  Substitutions §  Peanut: pad thai with almond/cashew/sunflower butter §  Milk: lasagna with vegan cheese §  Wheat: pizza with gluten free flours §  Egg: baked goods with egg replacer

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§  Which country to travel to •  Typical cuisine •  Language barrier

§  Research •  Airline accommodations •  Availability of familiar/chain restaurants •  Hotel restaurant, which may have more

experience with dietary restrictions •  Kitchenette/refrigerator in hotel room

§  Tools •  Language cards •  Smartphone dictionary/reader

§  Emergency services •  Nearest hospital, how to call ambulance

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Travel – before you go

§  Airplane •  Board early •  Bring your own food

§  In the country •  Carry safe snacks!! •  Avoid street carts •  If all else fails – find unprepared

food or familiar chains §  Safety •  Bring extra medications •  Wear medical identification,

especially if traveling alone

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Traveling tips

Camping and Hiking

§ Special considerations •  Shared food and equipment •  Far from emergency services

§ Tips •  Zero allergen if possible •  Dedicated storage/utensils/dishes/equipment •  Bring safe snacks!! •  Bring extra medications

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Relationships

§ 5.3-12% of food-allergic patients report symptoms after kissing a partner who has ingested their allergen

§ Peanut allergen in saliva – the “kissing study” •  Best method: avoid allergen partner is allergic to •  Best technique if allergen ingested: § Wait several hours §  Eat several allergen-free meals in between •  Brushing teeth/chewing gum did not dramatically

reduce peanut levels

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Halle+  et  al.  N  Engl  J  Med  2002;346:1833-­‐4.  Eriksson  et  al.  J  InvesDg  Allergol  Clin  Immunol  2003;  13:149-­‐54.  Maloney  et  al.  J  Allergy  Clin  Immunol  2006;118:719-­‐24.  

Living Life to the Fullest

§ What I’ve been able to do: •  Bake and cook a lot •  Lived in NYC and ate out at least once a week •  Flown on an airplanes since age 2yo •  Traveled to Europe, So America, Japan •  Gone camping and hiking •  Gone to concerts and sporting events

§ Ups and Downs •  Learn something when accidents happen •  Dream: travel to Southeast Asia, China, Africa

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Finding a Balance

Our Next Webinar

Understanding and Managing Sesame Allergy

Robert Wood, M.D.

Wednesday, October 14 1:00 – 2:00 PM ET Member registration opens Monday, September 28 General registration opens Monday, October 5