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In the article below, Ms. Broussard alleges that the current perception of increased incidence in food allergies is all a big conspiracy propagated by the Food Allergy and Anaphylaxis Network and the pharmaceutical companies that benefit from the public’s “paranoia”. She dismisses the severity of fatal food related anaphylaxis and displays shallow understanding of the research and the issues in this field.
It is disappointing to say the least that Harper’s magazine and WNYC allowed this article to make it to press and on the air without doing the requisite research on such an important topic.
Ms. Broussard’s article is merely another manifestation of the “backlash” to the media attention to food allergies (see “Mean Grownups” post in this blog). These articles would be useful if they were well-researched and well- informed on the issues, instead of merely just cashing in on a hot topic by trying to be controversial and in the process, making the lives of many truly food allergic patients more difficult.
“Everyone’s Gone Nuts”
The Exaggerated Threat of Food Allergies
by Meredith Broussard
in Harpers Jan 2008
Of little concern to most parents or educators only a generation ago,food allergies are now seen as a childhood epidemic. The American Academy of Pediatrics recently began recommending that peanuts be withheld until a child turns three; hundreds of food-allergy non profitsand local parents groups have formed; and six states have passed laws requiring food-allergy safety measures in their schools, with similar legislation currently being considered in Congress. Children are even being recruited to help battle this supposed threat, as in this Food Allergy & Anaphylaxis Network (FAAN) brochure, which enjoins young students to “Be a PAL” and protect the lives of their classmates. But the rash of fatal food allergies is mostly myth, a cultural hysteria cooked up with a few key ingredients: fearful parents in an age of increased anxiety, sensationalist news coverage, and a coterie of wellplaced advocates whose dubious science has fed the frenzy.
One of the first and most influential of the food-allergy non profits, FAAN has successfully passed off as fact its message that food allergies have become more prevalent and dire. Since 2005, more than 400 news stories have used FAAN’s estimates that allergic reactions to food send 30,000 Americans to emergency rooms each year and that 150 to 200 ultimately die. The group derived these figures from a 1999 study of a rural Minnesota community,in which 133 people over a five-year period were determined to have suffered anaphylaxis-an allergic reaction that can mean everything from going into shock to developing an itchy mouth. Yet only nine people in the study ever required hospitalization for anaphylaxis from any cause. As for
the death estimate, just one person died of anaphylactic shock, prompted not by food allergies but by exercise. The Centers for Disease Control and Prevention, in its most up-to-dare figures, recorded only 12deaths from food allergies in all of 2004. When asked about these statistical discrepancies, FAAN founder and CEO Anne Munoz-Furlong said focusing on any number
misses the point: “One child dying from food allergies is too many.”
In 2005, every major American media outlet covered the story of a teenager who died after kissing a boy who earlier in the day had eaten a peanut-butter sandwich. This “kiss of death” confirmed for countless nervous parents their worst fears: food-allergic children were in constant danger-they could “even die!” as FAAN warns here-from any sort of secondhand exposure to certain foods. (In a press release soon after the girl’s death, FAAN instructed food-allergic teens to tell “thatspecial someone that you can die …. Don’t wait for the first kiss.”) But there is simply no evidence that a food allergen can do serious harm if not ingested. Nicholas Pawlowski, an allergist at Children’s Hospital of Philadelphia, says he occasionally has to spread peanut butter on a patient’s arm to demonstrate to parents that their child will not die from casual contact with a nut. In the case of the peanut-butter kiss, a coroner later ruled, to no fanfare, that the girl had smoked pot
In addition to offering certificates to “PAL Heroes,” FAAN presents individuals and businesses with a service award named after Mufioz-Furlong’s daughter, a former food-allergic child who, like most people, grew out of her allergies. Anne Munoz-Furlong says she founded FAAN when her community didn’t seem to believe the threat to her child was real. Her organization
and others have certainly helped to change the perception of food allergies. (A recent Newsweek cover showing a pigtailed girl in a gas mask with a carton of milk in one hand and a peanut-butter sandwich in the other is typical of much recent coverage.) But all we know for certain now is that more parents think their children suffer from food allergies. Indeed, even the best allergy tests produce high rates of false positives, and most studies of childhood
prevalence interview no one under the age of eighteen. Ken Kochanek, a CDC statistician, says there are far too few recorded incidents of anaphvlactic shock triggered by food allergies to draw any sound epidemiological conclusions:”We can’t find any hard data that supports the severity.”
These hugging forms evoke a better world in which we all look out for our food-allergic friends. Such chumminess already exists within the world of food-allergy advocacy. The FAAN children’s website was built using a donation from Dey, the distributor of the Epipen adrenaline in,
jector; Dey and Verus Pharmaceuticals, the maker of Epilpen’s chief competitor, sponsor FAAN’s major annual fundraising event. (As part of its safety guidelines, FAAN suggests carrying an adrenaline injector at all times and regularly renewing the prescription.) Just about all the
leading food allergists also have ties to FAAN or the Food Allergy Initiative (FAI), an organization prone to even more extreme rhetoric. This intimacy helps explain why suspect statistical findings get published. For instance, the coauthors of an oft-cited study on the dangers facing food-allergic children at restaurants were Anne Mufioz-Furlong’s husband, who serves as a top FAAN executive, and a FAAN medical,board member whose research is funded in part by FAl. The latter isalso an editor at the leading allergy journal where the study appeared;the journal’s editor-in-chief is head of FAl’s medical board.
There is no question that food allergies are real. Yet instead of creating the healthy, happy children shown here, exaggerating the threat may actually do as much harm as the allergies themselves. The peril is now perceived as so great that psychosomatic reactions to foods and their odors are not uncommon. Recent surveys have also shown that children thought to have food allergies feel more overwhelmed by anxiety, more limited in what they believe they can safely accomplish, than even children with diabetes and rheumatological disease. One study documented how food-allergic youths become terror-stricken when inside places like supermarkets and restaurants,since they know that allergens are nearby. Such psychological distress is exacerbated by parents, who report keeping their children away from birthday parties and sending them to school in “No Nuts” Tshirts. Having been fed a steady diet of fear for more than two decades, we have become, it appears, what we eat.
Interview with Meredith Broussard on WNYC
Ms. Broussard’s blog on Failed Relationships (and apparently, Food Allergies)
In response to the Harper’s article, I am posting an excerpt of an interview with Dr. Michael Pistiner, an Allergy- Immunology fellow at Harvard conducted by Sloane Miller originally posted on MyAllergy.com
DR. MICHAEL PISTINER: According to Broussard, the 150 to 200 deaths and 30,000 episodes of anaphylaxis in the United States each year were based on a 5-year study (1983 to 1987) by Yocum and colleagues in Olmsted County, Minnesota (a population that is similar in demographics to the white American population).
This study was published in the well respected Journal of Allergy and Clinical Immunology in 1999. (Yocum et al. JACI. 1999;104:452)
This was a groundbreaking study. Though it’s 20 years old, the information continues to be useful and, for some statistical facts, unmatched. Its uniqueness and usefulness is that all of the medical records (clinic, hospital, ER, etc.) from all of the residents of this county were collected and reviewed, giving the author of the study and his colleagues the rare opportunity to identify even cases of anaphylaxis that were misdiagnosed, mislabeled and would have otherwise not been reported (Weiler. JACI. 1999; 104:271-3).
It is common that researchers and clinicians use the results of studies such as this one to estimate how many people in the nation’s population as a whole suffer from a disease. Based on the 2007 population estimated numbers, one could predict that there would be 32,523 cases of food-induced anaphylaxis and 211 related deaths. FAAN and the many reputable investigators who derive numbers from this study are not misrepresenting or exaggerating the statistics, they are using the available data.
SM: Remember the now famous story of a peanut-allergic teen that supposedly died from kissing her boyfriend who had eaten peanuts? The coroner later proved that she died from an asthma attack.
Can asthma be part of an allergic or anaphylactic reaction?
MP: Yes. Anaphylaxis can trigger asthma attacks that are notoriously difficult to treat. Wheezing, cough, chest tightness, and shortness of breath commonly occur during an asthma attack but are also life threatening symptoms seen during anaphylaxis (Wang. Clinical and Experimental Allergy, 37, 651-660). In some cases, respiratory symptoms can be the only manifestation (Moneret-Vautrin et al. Allergy. 2005: 60: 443-451). Anaphylaxis presenting in this way must be quickly treated with epinephrine. Prior to the advent of albuterol, epinephrine was the drug of choice for asthma exacerbation. When in doubt, use your epinephrine and call 911.
SM: How real is the threat from so-called “second-hand exposure,” like a kiss, to an allergen?
MP: Allergens can be transferred through saliva, so the second-hand exposure threat is real but entirely avoidable. Rosemary Hallett and colleagues at the University of California Davis School of Medicine reviewed data collected on 379 subjects with self-reported immediate nut or seed allergy and found that 20 subjects (5.3%) reported that they experienced reactions from kissing. Most of these reactions were mild but 20% did experience respiratory symptoms (Hallett et al. N Engl J Med 2002; 346:1833-4). Studies in other countries showed that people with food allergies reported that they experienced allergic symptoms after having “close physical contact (for example, kissing) with someone who recently ate something they were hypersensitive to (Eriksson et al. Journal of Investigational Allergology and Clinical Immunology. 2003 13(3):149-154).
In 2006, Maloney and colleagues conducted a study measuring the amount of peanut protein in 1 ml of saliva at certain times after eating a peanut butter sandwich and following various interventions. The study showed that soon after eating peanut butter salivary levels of peanut protein were high enough in some to cause a reaction. Additionally, 13% of subjects had detectable peanut protein in the saliva after 1 hour. No subjects had detectable salivary peanut protein several hours later and after eating a peanut-free meal. This study supports the reports of patients experiencing symptoms after kissing and demonstrates that oral contact with saliva, such as from sharing utensils or cups, can contain significant amounts of allergen and should be avoided. Additionally this study gives some guidance as far as interventions that can reduce the risk of a reaction other than complete avoidance (Maloney et al. JACI. V 118, (3) 719-724).
SM: Broussard quotes a CDC statistician who says, “There are far too few recorded incidents of anaphylactic shock triggered by food allergies to draw any sound epidemiological conclusions: ‘We can’t find any hard data that supports the severity’.”
MP: Studies determining the rates anaphylaxis and death from anaphylaxis have been notoriously difficult to conduct. Until recently, there has been little consensus as to its definition or clinical criteria and it is widely thought that it is underreported and underdiagnosed (Lieberman et al. Annals of Allergy, Asthma & Immunology. 2007;98:519-523).
Statistical information on deaths caused by food anaphylaxis is reliant on appropriate coding, interpretation of death certificates, and the correct diagnosis of cause of death (Neugut et al. ARCH INTERN MED/VOL 161, JAN 8, 2001) .
Even with imperfect methods of data collection and reporting, it is clear from the existing studies that food-related anaphylaxis is a real and growing global issue.
The European Academy Of Allergology And Clinical Immunology recently published a position paper on the management of anaphylaxis in childhood. In this paper, they review several studies supporting an increase in cases of anaphylaxis in North America and Europe. They reference studies that support an increase in anaphylaxis and food allergies in the United Kingdom and Canada.
In looking at the literature, it is clear that food-induced anaphylaxis is very real.
These studies have additionally shown us what risk factors are associated with death:
delayed epinephrine administrationbeing an adolescence or young adultasthmapeanut allergytree nut allergyprior minor reactionsnot asking about ingredients when dining out (Bock at al. Journal of Allergy and Clinical immunology. V119 (4) 1016-1017)The studies have also shown us what we can do to prevent these tragedies.
SM: Ms. Broussard implied that FAAN’s medical board and advising doctors are in some way colluding to disseminate exaggerated evidence. Do you know anything about FAAN’s studies’ objectivity?
MP: FAAN’s medical board and advising doctors are many of the leaders in food allergy and academic allergy and have been responsible for many of the studies leading to information that has dispelled fear and has increased patient safety. The studies published by these authors have been in well respected, peer reviewed journals which are scrutinized by other allergists and experts in the field prior to their publication. This identical process goes for studies that have received funding by FAAN. This process leaves little room for the dissemination of confabulated or manipulated data for self gain.
SM: Ms. Broussard wrote, “…exaggerating the threat may actually do as much harm as the allergies themselves. The peril is now perceived as so great that psychosomatic reactions to foods and their odors are not un-common”. Are you seeing this in your practice?
MP: I have experienced fear first hand while watching my own child have a severe, life threatening allergic reaction and not having the appropriate medication that could save his life. After my son recovered and my family had time to process what had happened we put into place well thought-out strategies, based on existing literature, to attempt to prevent this from happening again (avoidance strategies) and in the event that it did, a treatment plan to save his life (allergy action plan and epinephrine). Although we have a healthy respect for his allergy and are vigilant we are no longer afraid.
Dr. Michael Pistiner:
Dr. Michael Pistiner is currently a fellow in Allergy and Immunology at Children’s Hospital Boston, Harvard Medical School and is in his final year of the Scholars in Clinical Science Program of Harvard Medical School (masters program in patient based research). Over the last 2 years he has developed a special interest in pediatric food allergy and in the management of food allergy in schools. Within the last 4 months he has seen first hand the critical importance of community wide education as his pre-school aged son experienced anaphylaxis (life-threatening allergic reaction) after eating a small amount of walnut. He is committed to the use of practical food allergy education to replace fear and divisiveness with empowerment, confidence, and unity. Upon completion of his fellowship in July 2008, he will return to New York State and join Allergy & Asthma Consultants of Rockland & Bergen.
For references to the articles mentioned by Dr. Pistiner, please go to the original article on MyAllergyNetwork.com
Posted by: Scott Sicherer, MD January 03, 2008
(on the WNYC response forum)
Dr. Sicherer is Asst. Professor of Allergy and Immunology at Mt. Sinai Hospital
My name is Scott Sicherer. I am a pediatric allergist and researcher (government and private funded) specializing in food allergy. I am co-author on most of the studies that Ms. Broussard “quotes” in her Harpers article where she implies conspiracy and trivializes this significant medical problem. I am also a volunteer medical advisor to FAAN, an organization that she mocks but is, in my view, a non-profit that has clearly increased safety for those who suffer from this medical illness. I mention these points because by Ms. Broussard’s reasoning these personal involvements would probably disqualify me from discussing food allergy (e.g., conspiracy to exagerate). Apparently, NPR also sees some odd virtue in having a non-medical expert journalist be a spokesperson for health issues. I have never “posted” to sites like this and I am a bit reluctant to draw any additional attention to Ms. Broussard’s hurtful, confused and potentially dangerous comments, but I was obviously compelled to do so…It is easy to play “debate team” with any topic but here it has become irresponsible and, indeed, potentially dangerous. I am glad to see so many listeners have spoken up on their disappointment and made important points that I will not reiterate. I would be pleased to provide actual evidence-based educational information about food allergy on this “show”–but maybe that is too uninteresting for the media? I hope that is not the case.