Reviews and feature articleFood allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management
Section snippets
Prevalence
There are extensive data to suggest that food allergies are common (up to 10% affected),23 have been increasing in prevalence in the last 2 to 3 decades, appear to disproportionately affect persons in industrialized/westernized regions, and are more common in children compared with adults and that a rather short list of foods account for most of the more serious disease burden, namely peanut, tree nuts, fish, shellfish, egg, milk, wheat, soy, and seeds.3, 17, 24 However, the determination of
Pathogenesis/mechanisms
Molecular and cellular mechanisms of food allergy and tolerance have been reviewed recently65, 66, 67 and in a companion article.20 Major advances at the basic, translational, and clinical research levels have provided new insights into immunologic mechanisms leading to food allergies and suggest novel therapeutic and preventive strategies. The common mechanism leading to various food allergies is the breakdown of immunologic and clinical tolerance to an ingested food, which results in
Diagnosis
Arguably the most important single “test” for diagnosing a food allergy is the clinical history. To hone a diagnosis, the history must be reviewed in context of knowledge about the clinical manifestations and epidemiology of food allergy and with an understanding of disorders with similar clinical manifestations that might be misconstrued as food allergies. For example, consider a 3-year-old presenting with a complaint of generalized urticaria that started 15 minutes after peanut ingestion. If
Management
With the absence of a cure, effective management of food allergy requires avoidance of ingestion and prompt treatment in the event of an allergic reaction. Achieving successful avoidance and proper reactionary treatment can be complex and involves a variety of stakeholders beyond a patient and his or her family, including schools, the workplace, the food industry, government agencies, public health authorities, and others.17 Management concerns were reviewed recently,141 and here we highlight
Prevention
Many of the food allergy risk factors and hypotheses to explain the apparent increase in the prevalence of this disease, as described above (dual allergen exposure hypothesis,176 vitamin D hypothesis, dietary fat hypothesis, and hygiene hypothesis), lend themselves to interventions that could reduce the risk of food allergy (ie, primary prevention). A number of recent reviews,48, 177 including one in this issue of the Journal,22 describe opportunities for prevention. Selected approaches and
Future therapies
Treatment of food allergy is reviewed in a companion article in this issue of the Journal.19 It is acknowledged that allergen avoidance is an effective form of management, but avoidance is not tantamount to a true treatment. Allergen immunotherapy aims typically to provide desensitization, a temporary increase in threshold to provide a measure of safety that is dependent on continued treatment exposure. Ideally, a curative therapy would allow any amount of ingestion with no effect from
Summary
In the 4 years since our last review, remarkable advances have occurred in understanding, diagnosing, preventing, and treating food allergies. Insights into epidemiology have provided the basis for investigations of risk, management, and prevention that are already being translated into clinical use. Documentation of the significant disease burden has resulted in a surge of research. CRD has already improved the diagnostic armamentarium, and there are more sophisticated tests under development
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Disclosure of potential conflict of interest: S. H. Sicherer is employed by Icahn School of Medicine at Mount Sinai; has received grants from Food Allergy Research and Education, the National Institutes of Health (NIH)/National Institute of Allergy and Infectious Diseases (NIAID), and HAL Allergy; has received royalties from UpToDate and Johns Hopkins University Press; and is an Associate Editor for the American Academy of Allergy, Asthma & Immunology. H. A. Sampson has received grants from the NIAID (AI-44236; CoFAR; ITN); has consultant arrangements with Allertein Therapeutics, Hycor, and UCB; is employed by DBV Technologies as Chief Scientific Officer (0.6 FTE); has received royalties from UpToDate; and has received stock options from DBV Technologies.