Atara Beck’s daughter is so allergic to peanuts that she has to immediately get off a bus if someone else aboard opens a packet of Bamba, the common Israeli peanut puff snack. Just getting a whiff of the legume can make her sick, and eating one can send her into anaphylaxis.
“At first I was freaked out. I was terrified. I have another daughter with food allergies, and now one of my grandsons has them,” Beck said.
Beck’s daughters and grandson are far from alone, and evidence appears to show rising numbers of food allergy sufferers around the world in recent decades, especially in the West.
These allergies can cause symptoms such as stomach pain, diarrhea, and hives. At worst, they cause throat swelling, difficulty breathing, and anaphylactic shock that can lead to death.
Researchers around the globe are attempting to understand the nature of food allergies to alleviate those symptoms and to figure out why it seems more people are experiencing harmful reactions to food.
In Israel, one researcher-physician has literally cooked up an immunotherapy that she says has allowed young peanut allergy sufferers to build up immunity to the legume until they can eat it without getting sick.
Dr. Mona Kidon’s cookies, still under investigation, have raised hopes that allergy sufferers may one day not need to live in fear, and could also point the way to a deeper understanding of why human immune systems sometimes reject benign foods and how to prevent the growing phenomenon.
“The one modifiable risk factor that we can do something about to protect our children from developing life-threatening food allergies is to introduce foods as gradually and as straightforwardly as possible [from the first months of life],” said Kidon, who directs the pediatric allergy clinic at Safra Children’s Hospital. “The [Israeli] health system says to give tastes. I disagree. Tasting something is not going to protect you. We’re talking about introducing it into the child’s diet.”
A rash of allergies
More than 170 foods can provoke allergic reactions. The most common ones are peanuts, milk, eggs, wheat, nuts (hazelnuts, walnuts, almonds, cashews, pecans, etc.), soybeans, fish, crustaceans, and shellfish.
Kidon said she has seen more young people coming into her clinic, calling the apparent increase in the prevalence of food allergies “frightening.”
“We used to see allergies to eggs and milk in very young children, but then they would grow out of this by kindergarten. This isn’t the case anymore. The allergies aren’t going away. The numbers are three to four times higher in all age categories from birth through age 18 as compared to 20 years ago,” she said.
According to Kidon, the increase in food allergies is part of a multi-sectorial trend that includes similar surges in other allergies and immunological conditions such as asthma, atopic dermatitis, and diabetes.
In Israel, the rise in cases can feel particularly fraught. The country does not have regulations requiring uniform labeling of allergens on food, according to Dr. Eliana M. Aaron, a nurse practitioner who helps tourists with allergies navigate Israel’s food landscape. Restaurants can also play fast and loose, she warned.
“Many people who handle food don’t realize that if a single sesame seed splits on their finger and releases its oil, then their skin now has sesame on it and anything the finger touches becomes contaminated,” she said.
Theories abound as to why it seems more children have food allergies than in the past. One popular idea, known as “hygiene theory,” posits that better sanitation and cleanliness, as well as vaccinations against lethal diseases, have prevented young children from being exposed to various potential allergens, pathogens, and other possibly harmful elements. According to Kidon, a century of these advances has brought the infant mortality rate down from 15-20%, but it also means developing immune systems do not have a chance to be “educated.”
“This leaves an immune system that is not well educated and can look around and make bad decisions. Those bad decisions are to fight things that are in your environment but are not detrimental to you. These include food allergens like milk, eggs, and peanuts, and environmental allergies like mites and pollen,” Kidon explained.
“Once the immune system decides to recognize these proteins and react to them, it is really hard to walk things back and re-educate the immune system not to react.”
She also pointed to geographic factors that may be contributing to the rise: globalization means children around the world are exposed to foods that were not previously in their diet, and this can trigger allergies in those with genetic predispositions. She cited apparently increasing rates of sesame allergies in the general US population, which has been attributed to tahini and similar products made with the seed becoming more popular and widespread.
Kidon also gave the example of children in China eating more peanuts gram for gram than American children. A decade ago, peanut allergies in the US were still much higher than in China, but today, that seems to be changing.
“Nowadays, we are seeing more peanut allergies among Chinese children because the way they are exposed to peanuts is changing,” said Kidon. “They are increasingly eating peanut butter, which is more allergenic because of the way it is made, with the roasting of the peanuts.”
But some have questioned the data underpinning claims of a rise in allergy prevalence.
Dr. Robert Bocian, a professor of allergy-immunology at Stanford University, said higher rates could also be attributed to changes in awareness and the way allergies are diagnosed.
“In other words, there is a greater recognition of the possibility of food allergy and a greater ease in diagnosing food allergy by history, allergy testing — either by skin or blood — and with confirmation by oral challenge where that’s indicated,” said Bocian, who is also co-founder and chief scientific officer at Allermi, a company that offers customized multi-ingredient nasal sprays for allergies.
Building a better peanut
In the last decade, researchers have been studying whether oral immunotherapy is a safe and effective way to treat food allergies. Kidon is a proponent of controlled protocols by which medical staff slowly and carefully introduce a child with a food allergy to the allergen as a way of building up immunity against it.
“The idea is that you want to re-educate your immune system not to react in the way that causes the allergy… If you want to bring the child to a point where they can eat safely, you have to feed them those allergens that they are allergic to,” Kidon explained.
The idea is not without its detractors. Bocian noted that feeding children the foods that make them sick comes with significant risks, and often fails. He said he feels more comfortable with advising patients to simply avoid the allergens.
“Oral immunotherapy for food allergy is experimental and controversial. In certain instances, it works. But even the definition of what it means to work is controversial,” he said. “In some instances it meets with significant side effects, not infrequently requiring the use of an epinephrine injection to reverse an anaphylactic reaction.”
Kidon has worked for the last two decades to find a safe way to introduce oral immunotherapy to children toddler age and up with peanut allergies. She worked with Dr. Ran Hovav of the Volcani Institute – Agricultural Research Institute to develop a peanut whose protein does not make the body recognize it as an allergen, but at the same time still educates the immune system to be less allergic over time. The project is part of the Sheba Impact tech transfer program.
“It took us seven years for the development of the peanut and then proving the concept that the peanut is less allergenic through skin tests,” she said.
Using a proprietary recipe, Kidon used the special peanuts to make her “Mona Cookies.” She claims that even patients who are very allergic to peanuts could ingest the peanut protein in the special cookies at 10 times the amount that would normally make them sick, without having an allergic reaction.
The next step was to show that over time, exposure to the protein in the special peanut cookies enabled those patients to eat regular peanuts without incident.
“We have completed the phase 2 clinical studies. We have more than 30 children right now eating regular peanuts in huge amounts. Some of our exit trials involved coming into the clinic and eating 100 Bamba puffs. If there is no problem with that, then a child can go out into the world and eat whatever amount of peanuts they want,” Kidon reported.
The catch is that the children must keep eating regular peanuts almost daily to maintain this non-allergic status.
“The next phase is to see if these kids can stop eating peanuts so often and sustain unresponsiveness,” Kidon said.
Until now, Kidon has given parents the ingredients to make the cookies at home for their children. To submit an investigational new drug application to the FDA, she needs to find a way to standardize the production of the cookies and conduct an international double-blind placebo control study.
Kidon also has immunotherapy cookies for sesame, egg, and milk allergies in various stages of development.
Getting in early
Doctors used to advise parents to wait months — if not years — before introducing their babies to allergy-inducing foods.
Today, if there is no family history of allergy (or if a baby with a family history of allergy has been cleared through testing), then there is no reason to wait.
“Likewise, pregnant and nursing mothers are no longer encouraged to refrain from eating a host of potentially allergenic foods. In several studies this has been shown to result in a lesser degree of food allergy in the growing child,” Bocian said.
The American Academy of Pediatrics has recommended that all the main food allergens should be introduced to a baby’s diet by the age of seven months.
In Israel, many parents have relied on the results of a well-known 2008 study by Prof. Yitzhak Katz and others that compared Jewish children in Israel and the UK. Controlling for a variety of factors, the study showed that the British children had a 10 times higher rate of peanut allergy than their Israeli counterparts.
The conclusion was that early introduction to peanuts (via Bamba) in infancy could likely be the reason for the difference.
“The data that we have from research all over the world, including from Israel, points to the fact that feeding as early as possible and with the most variety is best,” Kidon advised. “Everything — including allergenic foods — should enter into a children’s diet as soon as possible.”
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