• Section 5. Common Food Allergies

    Section Summary

    The following topics are included in this section:

    • Food Allergen Labeling and Consumer Protection Act (FALCPA)
    • Most common food allergens

        


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    Food Allergen Labeling and Consumer Protection Act (FALCPA)

    While more than 160 foods can cause allergic reactions in people with food allergies, the Food Allergen Labeling and Consumer Protection Act (FALCPA), identifies the eight most common allergenic foods. These foods account for 90 percent of food allergic reactions, and are the food sources from which many other ingredients are derived.14

    The eight foods identified by the law are:

    1. Milk
    2. Eggs
    3. Fish (e.g., bass, flounder, cod)
    4. Crustacean shellfish (e.g. crab, lobster, shrimp)
    5. Tree nuts (e.g., almonds, walnuts, pecans)
    6. Peanuts
    7. Wheat
    8. Soybeans

    These eight foods, and any ingredient that contains protein derived from one or more of them, are designated as “major food allergens” by FALCPA.

    FDA Facts

    The Food Allergen Labeling and Consumer Protection Act (FALCPA), which took effect January 1, 2006, mandates that the labels of foods containing major food allergens (milk, eggs, fish, crustacean shellfish, peanuts, tree nuts, wheat and soy) declare the allergen in plain language, either in the ingredient list or the following notice: 

    • The word “Contains” followed by the name of the major food allergen – for example, “Contains milk, wheat” – or

    • A parenthetical statement in the list of ingredients – for example, “albumin (egg)”

      

    Such ingredients must be listed if they are present in any amount, even in colors, flavors, or spice blends. Additionally, manufacturers must list the specific nut (e.g., almond, walnut, cashew) or seafood (e.g., tuna, salmon, shrimp, lobster) that is used.

    All product labels should be read carefully before purchasing and consuming any item. Ingredients in packaged food products may change without warning, so check ingredient statements carefully every time you shop. If you have questions, call the manufacturer.

    As of this time, the use of advisory labels (such as “May Contain”) on packaged foods is voluntary, and there are no guidelines for their use. However, the FDA has begun to develop a long-term strategy to help manufacturers use these statements in a clear and consistent manner, so that consumers with food allergies and their caregivers can be informed as to the potential presence of the eight major allergens.

    Food Allergen “Advisory” Labeling

    FALCPA’s labeling requirements do not apply to the potential or unintentional presence of major food allergens in foods resulting from "cross-contact" situations during manufacturing, e.g., because of shared equipment or processing lines. In the context of food allergens, "cross-contact" occurs when a residue or trace amount of an allergenic food becomes incorporated into another food not intended to contain it. FDA guidance for the food industry states that food allergen advisory statements, e.g., "may contain [allergen]" or "produced in a facility that also uses [allergen]" should not be used as a substitute for adhering to current good manufacturing practices and must be truthful and not misleading. FDA is considering ways to best manage the use of these types of statements by manufacturers to better inform consumers.15

    Most Common Food Allergens

    The most common food allergens are the proteins in cow’s milk, eggs, peanuts, wheat, soy, fish, shellfish and tree nuts. In some food groups, especially tree nuts and seafood, an allergy to one member of a food family may result in the person being allergic to other members of the same group. This is known as cross-reactivity. Cross-reactivity for other food families is not common.

    #1.  Peanut Allergy

    Peanut Butter JarPeanut allergy is one of the most common food allergies. Peanuts can cause a severe, potentially fatal, allergic reaction (anaphylaxis).16

    Peanuts are not the same as tree nuts (almonds, cashews, walnuts, etc.), which grow on trees. Peanuts grow underground and are part of a different plant family, the legumes. Other examples of legumes include beans, peas, lentils and soybeans. If a person is allergic to peanuts, they do not have a greater chance of being allergic to another legume (including soy) than they would to any other food.

    Trace amounts of peanut can cause an allergic reaction. Casual contact with peanuts, such as touching peanuts or peanut butter residue, is less likely to trigger a severe reaction. Casual contact becomes a concern if the area that comes into contact with peanuts then comes into contact with the eyes, nose or mouth (for example, a child with peanut allergy gets peanut butter on her fingers, and then rubs her eyes).

     Avoiding Peanuts

     Avoid foods that contain peanuts or any of these ingredients:

    Peanut a2

    The following list highlights examples of where peanuts have been unexpectedly found (e.g., on a food label for a specific product, in a restaurant meal, in creative cookery). This list does not imply that peanuts are always present in these foods; it is intended to serve as a reminder to always read the food label. Peanut is sometimes found in the following:

    Peanut e

     #2. Tree Nut Allergies

    Tree Nut AllergyTree nut allergy is one of the most common food allergies in children and adults. Tree nuts can cause a severe, potentially fatal, allergic reaction (anaphylaxis).17                           

    An allergy to tree nuts tends to be lifelong; recent studies have shown that approximately 9 percent of children with a tree nut allergy eventually outgrow their allergy. Younger siblings of children who are allergic to tree nuts may be at increased risk for allergy to tree nuts.

    Tree nuts include, but are not limited to, walnut, almond, hazelnut, cashew, pistachio, and Brazil nuts. These are not to be confused or grouped together with peanut, which is a legume, or seeds, such as sunflower or sesame.

    A person with an allergy to one type of tree nut has a higher chance of being allergic to other types. Therefore, many experts advise patients with allergy to tree nuts to avoid all nuts. Patients may also be advised to also avoid peanuts because of the higher likelihood of cross-contact with tree nuts during manufacturing and processing.

    Avoiding Tree Nuts

    Avoid foods that contain tree nuts or any of these ingredients:

    Tree Nut 1

    Tree nuts are sometimes found in the following:

    Tree Nut 2

    Some Unexpected Sources of Tree Nuts

    Tree nut proteins may be found in cereals, crackers, cookies, candy, chocolates, energy bars, flavored coffee, frozen desserts, marinades, barbeque sauces and some cold cuts, such as mortadella. Some alcoholic beverages may contain nut flavoring and should be avoided. These beverages are not currently regulated by FALCPA.

     

    #3. Milk Allergy

    Milk Poured

    Allergy to cow’s milk is the most common food allergy in infants and young children. Symptoms of a milk allergy reaction can range from mild, such as hives, to severe, such as anaphylaxis. To prevent a reaction, strict avoidance of cow’s milk and cow’s milk products is essential. Always read ingredient labels to identify cow’s milk ingredients.18

    Nearly all infants who develop an allergy to milk do so in their first year of life. Most children eventually outgrow a milk allergy. The allergy is most likely to persist in children who have high levels of cow’s milk antibodies in their blood.

    Sensitivity to cow’s milk varies from person to person. Some people have a severe reaction after ingesting a tiny amount of milk. Others have only a mild reaction after ingesting a moderate amount of milk. Reactions to milk can be severe and life-threatening (read more about anaphylaxis).

    Differences between Milk Allergy and Lactose Intolerance

    Milk allergy should not be confused with lactose intolerance. A food allergy is an overreaction of the immune system to a specific food protein. When the food protein is ingested, in can trigger an allergic reaction that may include a range of symptoms from mild symptoms (rashes, hives, itching, swelling, etc.) to severe symptoms (trouble breathing, wheezing, loss of consciousness, etc.). A food allergy can be potentially fatal.

    Unlike food allergies, food intolerances do not involve the immune system.  People who are lactose intolerant are missing the enzyme lactase, which breaks down lactose, a sugar found in milk and dairy products. As a result, lactose-intolerant patients are unable to digest these foods, and may experience symptoms such as nausea, cramps, gas, bloating and diarrhea. While lactose intolerance can cause great discomfort, it is not life-threatening.

    Avoiding Milk

    Food products may change without warning, so check ingredient statements carefully each time.

    Avoid foods that contain milk or any of these ingredients:

    Milk 1

    Milk is sometimes found in the following:

    Milk 2

    Some Unexpected Sources of Milk

    The following list highlights examples of where milk has been unexpectedly found (e.g., on a food label for a specific product, in a restaurant meal, in creative cookery). This list does not imply that milk is always present in these foods.

    Milk 3

    #4. Egg Allergy

    EggsEgg allergy is one of the most common food allergies in children, second only to milk allergy. Symptoms of an egg allergy reaction can range from mild, such as hives, to severe, such as anaphylaxis. Most children eventually outgrow an allergy to egg.19                

    While the whites of an egg contain the allergenic proteins, patients with an egg allergy must avoid all eggs completely. This is because it is impossible to separate the egg white completely from the yolk, causing a cross-contact issue.

    Egg Allergy and Vaccines

    Some vaccines contain egg protein. The recommendations of the American Academy of Pediatrics (AAP) acknowledge that the MMR vaccine (measles-mumps-rubella) can be safely administered to all patients with egg allergy. These recommendations have been based, in part, on scientific evidence that supports the routine use of one-dose administration of the MMR vaccine to patients with an egg allergy. This includes those patients with a history of severe, generalized anaphylactic reactions to egg.

    Influenza vaccines usually contain a small amount of egg protein. If a child is allergic to eggs, speak to the doctor before administering a flu shot.

    Avoiding Eggs

    Avoid foods that contain eggs or any of these ingredients:

    Eggs 1

    Eggs are sometimes found in the following:

    Eggs 2

    Some Unexpected Sources of Egg

    The following list highlights examples of where eggs have been unexpectedly found (e.g., on a food label for a specific product, in a restaurant meal, in creative cookery). This list does not imply that eggs are always present in these foods.

    • Eggs have been used to create the foam or topping on specialty coffee drinks and are used in some bar drinks.
    • Some commercial brands of egg substitutes contain egg whites.
    • Most commercially processed cooked pastas (including those used in prepared foods such as soup) contain egg or are processed on equipment shared with egg-containing pastas. Boxed, dry pastas are usually egg-free, but may be processed on equipment that is also used for egg-containing products. Fresh pasta is sometimes egg-free, too.
    • Egg wash is sometimes used on pretzels before they are dipped in salt.

      

    #5. Wheat Allergy

    WheatWheat allergy is most common in children, and is usually outgrown before reaching adulthood, often by age three. Symptoms of a wheat allergy reaction can range from mild, such as hives, to severe, such as anaphylaxis.20               

    A wheat allergy can present a challenge for the diet as well as for baking, because wheat is the nation’s predominant grain product. Someone on a wheat-restricted diet can eat a wide variety of foods, but the grain source must be something other than wheat. In planning a wheat-free diet, look for alternate grains such as amaranth, barley, corn, oat, quinoa, rice, rye, and tapioca. When baking with wheat-free flours, a combination of flours usually works best.

    Differences between Wheat Allergy and Celiac Disease or Gluten Intolerance

    A wheat allergy should not be confused with “gluten intolerance” or celiac disease. A food allergy is an overreaction of the immune system to a specific food protein. When the food protein is ingested, in can trigger an allergic reaction that may include a range of symptoms from mild symptoms (rashes, hives, itching, swelling, etc.) to severe symptoms (trouble breathing, wheezing, loss of consciousness, etc.). A food allergy can be potentially fatal.

    Celiac disease (also known as celiac sprue), which affects the small intestine, is caused by an abnormal immune reaction to gluten. Usually diagnosed by a gastroenterologist, it is a digestive disease that can cause serious complications, including malnutrition and intestinal damage, if left untreated. Individuals with celiac disease must avoid gluten, found in wheat, rye, barley and sometimes oats.

    People who are allergic to wheat often may tolerate other grains. However, about 20 percent of children with wheat allergy also are allergic to other grains. Be sure to ask your doctor whether foods containing barley, rye, or oats are safe for you or your child to eat.

    Avoiding Wheat

    Avoid foods that contain wheat or any of these ingredients:

     Wheat 1

    Wheat is sometimes found in the following:

    • Glucose syrup
    • Surimi
    • Soy sauce
    • Starch (gelatinized starch, modified starch, modified food starch, vegetable starch)

     

    Some Unexpected Sources of Wheat

    Always read ingredient labels carefully. Wheat has been found in some brands of ice cream, marinara sauce, play dough, potato chips, rice cakes, turkey patties and hot dogs.

    Wheat also may be found in ale, baking mixes, baked products, batter-fried foods, beer, breaded foods, breakfast cereals, candy, crackers, processed meats, salad dressings, sauces, soups, soy sauce, and surimi. Some types of imitation crabmeat contain wheat.

     

    #6. Soy Allergy

    LegumesSoybean allergy is one of the more common food allergies, especially among babies and children. Approximately 0.4 percent of children are allergic to soy.  Studies indicate that an allergy to soy generally occurs early in childhood and often is outgrown by age three. Research indicates that the majority of children with soy allergy will outgrow the allergy by the age of 10.21

    Allergic reactions to soy are typically mild; however, although rare, severe reactions can occur (read more about anaphylaxis). To prevent a reaction, strict avoidance of soy and soy products is essential.

    Soybeans are a member of the legume family, which include plant species that bear seed pods that split upon ripening. Some examples of other legumes include beans, peas, lentils and peanut. People with a soy allergy are not necessarily allergic to other legumes. If you are allergic to soy, you do not have a greater chance of being allergic to another legume (including peanut) than you would to any other food.

    In the United States, soybeans are widely used in processed food products. Soybeans alone are not a major food in the diet, but because soy is used in so many products, eliminating all those foods can result in an unbalanced diet.

    Avoiding Soy

    Avoid foods that contain soy or any of these ingredients:

    Soy 1

    Soy is sometimes found in the following:

    • Asian cuisine
    • Vegetable gum
    • Vegetable starch
    • Vegetable broth

    Some Unexpected Sources of Soy

    Soybeans and soy products are found in many foods, including baked goods, canned tuna and meat, cereals, cookies, crackers, high-protein energy bars and snacks, infant formulas, low-fat peanut butter, processed meats, sauces, and canned broths and soups.

    Asian cuisines are considered high-risk for people with soy allergy due to the common use of soy as an ingredient and the possibility of cross-contact, even if a soy-free item is ordered.

       

    #7. Fish Allergy

    Salmon AllergyFinned fish can cause severe allergic reactions (such as anaphylaxis). Approximately 40 percent of people with fish allergy experienced their first allergic reaction as adults.

    Salmon, tuna and halibut are the most common kinds of finned fish to which people are allergic.  More than half of all people who are allergic to one type of fish also are allergic to other fish, so allergists often advise their fish-allergic patients to avoid all fish. If you are allergic to a specific type of fish but want to have other fish in your diet, talk to your doctor about the possibility of allergy testing for specific fish.

    Finned fish and shellfish do not come from related families of foods, so being allergic to one does not necessarily mean that you must avoid both.

    Avoiding Fish 

    It has been estimated that there are upwards of 20,000 species of fish. Although this is not an exhaustive list, allergic reactions have been commonly reported to:

    Fish 1

    Some Unexpected Sources of Fish

    The following list highlights examples of where fish has been unexpectedly found (e.g., on a food label for a specific product, in a restaurant meal, in creative cookery).

    • Caesar salad and Caesar dressing
    • Worcestershire sauce
    • Bouillabaisse
    • Imitation or artificial fish or shellfish (surimi, also known as “sea legs” or “sea sticks,” is one example)
    • Meatloaf
    • Barbecue sauce
    • Caponata, a Sicilian eggplant relish

        

    #8. Shellfish

    ShrimpShellfish can cause severe allergic reactions (such as anaphylaxis). This allergy usually is lifelong. Approximately 60 percent of people with shellfish allergy experienced their first allergic reaction as adults. Shrimp, crab and lobster cause most shellfish allergies. Finned fish and shellfish do not come from related families of foods, so being allergic to one does not necessarily mean that you must avoid both.22

    There are two kinds of shellfish: crustacea (such as shrimp, crab and lobster) and mollusks (such as clams, mussels, oysters and scallops). Reactions to crustacean shellfish tend to be particularly severe. If you are allergic to one group of shellfish, you might be able to eat some varieties from the other group. However, since most people who are allergic to one kind of shellfish usually are allergic to other types, allergists usually advise their patients to avoid all varieties. If you have been diagnosed with a shellfish allergy, do not eat any shellfish without first consulting your doctor.

    To prevent a reaction, strict avoidance of shellfish and shellfish products is essential. Always read ingredient labels to identify shellfish ingredients. In addition, avoid touching shellfish, going to the fish market, and being in an area where shellfish are being cooked (the protein in the steam may present a risk).

    Avoiding Shellfish

    Avoid foods that contain shellfish or any of these ingredients:

    • Barnacle
    • Crab
    • Crawfish (crawdad, crayfish, ecrevisse)
    • Krill
    • Lobster (langouste, langoustine, Moreton bay bugs, scampi, tomalley)
    • Prawns
    • Shrimp (crevette, scampi)

    It is important to note that mollusks are not considered major allergens under FALCPA and may not be fully disclosed on a product label.

    Shellfish are sometimes found in the following:

    • Bouillabaisse
    • Cuttlefish ink
    • Glucosamine
    • Fish stock
    • Seafood flavoring (e.g., crab or clam extract)
    • Surimi

       

    #9. Other Allergens

    Although the list below is by no means exhaustive, allergic reactions have been reported to corn, gelatin, meat (beef, chicken, mutton, and pork), seeds (sesame, sunflower, and poppy being the most common), and spices such as caraway, coriander, garlic, and mustard.         

    Allergic reactions to fresh fruits and vegetables, such as apple, carrot, peach, plum, tomato and banana, to name a few, are often diagnosed as Oral Allergy Syndrome.

    Corn Allergy

    Allergic reactions to corn are rare and a relatively small number of case reports can be found in medical literature. However, the reports do indicate that reactions to corn can be severe. Reactions to corn can occur from both raw and cooked corn. Individuals who are allergic to corn should receive individualized expert guidance from their allergists.

    Meat Allergy

    Allergies to meats, such as beef, chicken, mutton or pork, are also rare.  A person who is allergic to one type of meat may not need to avoid other types of meat. Heating and cooking meat can reduce the allergenicity of product.

    Gelatin Allergy

    Gelatin is a protein that is formed when skin or connective tissue is boiled. Although rare, allergic reactions to gelatin have been reported.

    Many vaccines contain porcine gelatin as a stabilizer. Allergy to gelatin is a common cause of an allergic reaction to vaccines. Individuals who have experienced symptoms of an allergic reaction after consuming gelatin should discuss this with their health care provider before getting vaccinated. If a severe allergy to gelatin is known, vaccines that contain gelatin as a component should be avoided.

    Seed Allergy

    Allergic reactions to seeds can be severe. Sesame, sunflower, and poppy seeds have been known to cause anaphylaxis.

    The estimated prevalence of seed allergy is not known. In a study published in 2010, however, researchers at New York’s Mount Sinai School of Medicine concluded that 0.1 percent of the general population may have a sesame allergy, based on a national survey that focused primarily on the prevalence of peanut and tree nut allergy.

    Seeds are often used in bakery and bread products, and extracts of some seeds have been found in hair care products.

    Some seed oils are highly refined, a process that removes the proteins from the oil. However, as not all seed oils are highly refined, individuals with a seed allergy should be careful when eating foods prepared with seed oils.

    Spice Allergy

    Allergies to spices, such as coriander, garlic, and mustard, are rare and are usually mild, although severe reactions to spices have been reported. Some spices cross-react with mugwort and birch pollen, so patients who are sensitive to these environmental allergens are at a higher risk for developing an allergy to spice.

     

    Section 4. Food Allergy Symptoms, Diagnosis, and TestingSection 6. Managing Food Allergies