Food Allergies: Sorting out Truth From Fiction

In my previous incarnation as an emergency physician (before I discovered “The Way” of correctional medicine), I saw a lot of cases of acute allergic reactions. It is a very common emergency complaint; I have probably seen hundreds in my career. But when I began my jail medicine career, I was still unprepared for the sheer volume of food allergies claimed by inmates. Who knew so many inmates had so many food allergies?

Of course, most of them don’t. Most just don’t want to eat something on the jail menu. Inmates believe that if they claim an allergy to a food they dislike, you cannot serve it to them. They will claim allergies to tomatoes, onions, mayo, etc., when really, they just don’t like these foods. Tuna casserole doesn’t seem very popular, for some reason.

However, some inmates truly are allergic to some foods and we can potentially harm them by ignoring their complaint. How do we correctional medical staff sort out the truly allergic from the “I don’t like it” crowd? It is an important question because we certainly don’t want anyone in our care to have a sudden anaphylactic reaction!

To answer this question, we need to understand the mechanism of food allergies, the overall incidence of food allergies as well as the incidence of death, how to accurately diagnose a true food allergy and what steps to take once we find one. All of this is important to make accurate risk assessments.

Understanding Food Allergies
The incidence and causes of food allergies vary markedly with age. For the most part, food allergies are a problem of childhood. In children, the most common food allergies are milk, eggs, wheat and nuts. However, most of these allergies abate with time. So a child who is allergic to eggs most likely will be able to eat eggs as an adult. One important exception to this rule is peanuts and tree nuts (like almonds, cashews, etc.). Those allergies tend to persist into adulthood. The most common adult food allergies are peanuts, tree nuts, shellfish and fish.

True food allergies come in two types. The first is called IgE-mediated allergic reactions because the IgE antibody is essential to the reaction. The second type of allergic reactions does not involve IgE and so, of course, is called non-IgE mediated food allergies. The best example of this is celiac disease, in which patients are allergic to gluten found in grains. Non-IgE-mediated allergic reactions are typically indolent and chronic and may not be discovered for several years.

IgE is an antibody that is created by the body to react to a specific antigen substance. This substance can be ragweed pollen, of course, but it also can be food proteins. Later on, if the person eats the same food that triggered the creation of IgE, the protein locks onto the IgE, causing the release of inflammatory chemicals such as histamine, cytokinens, prostaglandins and leukotrienes.

The most common symptom caused by these inflammatory chemicals is hives, the itchy splotchy rash we have all seen. The second most common symptom is angio­edema, which is swelling of the face. Angioedema most commonly occurs around the eyes but also rarely can cause the tongue to swell. Third and less frequently, the allergic reaction can cause bronchospasm in the lungs, so the patient wheezes as if having an asthma attack. Finally, the patient can suffer anaphylaxis, which consists of acute vasodilation leading to hypotension, shock and possibly death.

All of these allergic symptoms occur within minutes of eating. Allergic hives that occur several hours after eating are probably not due to the food.

Of these four allergic symptoms, by far the most common are hives and angioedema. However, most of the time hives and andioedema are nuisances rather than life-threatening emergencies. On the other hand, anaphylaxis is an acute medical emergency. Anaphylaxis is the allergic reaction we should fear the most and work to prevent.

The Centers for Disease Control and Prevention estimates that approximately 100 deaths from food allergies occur in the United States each year. Almost all of the reported deaths occurred in teenagers or young adults who knew that they were allergic to the food they ate. By far, the most common culprit foods are peanuts and tree nuts (85%), with shellfish coming in second. In contrast, 400 deaths due to allergic reactions to penicillin occur every year, and most of those occur in people who have no idea that they are allergic.

Risk Assessment Tips
You can use these principles to do a risk assessment for individual patients. Patients at higher risk of an anaphylactic allergic reaction are those who are younger (late teens, early 20s) who state an allergy to peanuts, tree nuts or shellfish and who have had a previous documented allergic reaction. Patients with a lower risk are older patients who state an allergy to a low-risk food (say, onions or peppers) and cannot document a previous severe allergic reaction. Someone who has had a severe allergic reaction to a food in the past should be able to tell you about an emergency room visit, allergy testing, EpiPen prescriptions and how they avoid the food in restaurants and while shopping.

However, there are other tests that can help you sort out the confusing cases. The first is a CAP RAST test. This is a blood test that measures the levels of IgE to a certain specific allergen, say peanuts. We then draw blood for a CAP RAST for peanuts. A positive result is peanut-specific IgE of greater than 2.0 Ku/L. If the test comes back at, say, 0.35 Ku/L, then the patient is not allergic. The test is quite sensitive but not specific. That means that you can believe a negative result, but patients with positive results might still not be allergic. The main problem with a CAP RAST test is that it is expensive—around $45. However, that is probably less expensive than the cost in time and energy to put out a special diet.

A second test is the skin prick test. The patient’s skin is pricked with a small instrument and a drop of allergen extract is placed on the site. If a patient is truly allergic, she will form an itchy wheal at the site within 5 to 15 minutes. The advantage of this test is that it is cheap and easy to do and the results are immediate. The disadvantage is that you have to order and store the extracts and be trained in the procedure, usually by an allergist.

“Food challenge” tests probably should not be done in a correctional setting. This is where you simply feed the food to the patient and wait to see what happens. If this is done in a double-blinded fashion it is the most accurate test of all. Sometimes patients will have done their own food challenge without knowing it. For example, a patient might say he is allergic to eggs but admits to eating pasta and mayonnaise, both of which are made with eggs. He is likely not truly allergic.

Setting Policies
Of course, the easiest way to deal with the foods most likely to cause severe allergic reactions is not to serve them at all. Most jails do not serve shellfish to inmates. (If your jail does, write to me; I would like to know about it!) If your facility uses tree nuts in cookies, consider eliminating them from the menu. Then you won’t have to worry about it. That just leaves peanuts as the food served in most prisons and jails that has the greatest potential to cause allergic reactions.

Once you have discovered that a patient has a positive CAP RAST test to peanuts, what should you do? It may not be enough to simply order a peanut-free diet. Since allergic reactions can be triggered by even a small amount of allergen contact, you should consider these other factors:

1. You probably have peanut-containing items on your commissary. Should this inmate have a commissary restriction?

2. Should this inmate be allowed to work in the kitchen, preparing peanut butter sandwiches?

3. Should this inmate be housed with other inmates who may be eating peanut butter sandwiches right next to him?

4. What about an Epi-Pen? Where should it be kept?

I hope this information will make you a little more confident the next time an inmate says she is allergic to, say, “all vegetables” (as one patient told me once). You can also use these principles of risk assessment, history and testing to write a policy and procedure for the clinical assessment of food allergies. If you need help, e-mail me and I will send you mine.

Have you had problems with food allergies at your facility?  Tell us about it in comments!

This article was first published in CorrectCare Winter 2011


67 thoughts on “Food Allergies: Sorting out Truth From Fiction

  1. Pingback: Eating Out With Food Allergies « John Hudson Blog

  2. I would like to get more of your information on allergy testing, policies and procedures for assessing food allergies. Please forward anything that may help our little rural jail handle this situation better.

    Thank you!

  3. I personally have Oral Allergy Syndrome. I can’t eat any fruit with a pit without violent projectile vomiting and a swollen, numb and tingly tongue. But my only ‘true’ allergy is to Birch tree pollen. Google it. Good reading. We had a patient come in claiming an allergy to an odd item. It was one that is frequently claimed due to the pt. not ‘liking’ the item so his claim was minimized and pushed aside. He was an uninsured young man so had no records we could get to confirm. He coped by trying to avoid the item on his tray, but one day slipped up. Turns out he had the same reaction to onions that I do to peaches and such. He was ignored because of an atypical and little known (but relatively common) reaction. But since we saw the reaction there is now no doubt in his medical record. He is the only person I have heard of with an allergy to onions! Don’t judge and don’t assume they are lying!

  4. At our facility, if an imate claims a food allergy, they will be given a diet free of that alleged allergen pending results of an allergy test. If the inmate cancels the allergy test the special diet will also be canceled. If it turns out the inmate is not allergic to the substance, their diet will be canceled and they are charge the cost of the allergy test. If it turns out they are allergic to the substance their diet continues, and there is no charge for the allergy test.

  5. I am a Nurse Practitioner and Manager at a correctional facility in Ontario Canada. My physician partner and I are less than a year in corrections. First off, I want to thank you for your work and willingness to share your expertise, I found this site in my first few weeks here and it has been invaluable in helping my physician and I navigate this new environment. I would appreciate any policy procedures information you can share to help us sort through our many diet requests.

  6. I am the sole nurse in a County Detention Center, the company that I work for doesn’t seem to have a real “policy”in place in regards to food allergies. Its becoming a real problem here as many of our inmates are “frequent flyers” and are reporting allergies that they have never reported before and seemingly know the right symptoms to tell you of their reactions. We dont have any RAST testing on our Lab Formulary either. Just curious as your thoughts? Thanks

    • This illustrates one of the basic principles of Correctional Medicine, which is “Everything is discussed in the dorms!” If inmates find out they can get a special diet by just saying the magic words of “I’m allergic to (whatever they don’t like),” then they will pass that information around and lots of them will take advantage of this benefit. I know of one jail where over 60% of the inmates where on a special diet of some kind!

      All labs, including yours, do IgE testing. They may not call it a RAST (which is a dated term), and it might be a send out, but they can run it. I assume that your Lab Formulary means that you cannot order this test without specdial permission. Well, it is time to get special permission! Call a meeting of your jail administration and whoever you need in your company and discuss an approach to food allergies. The jail administration will love you if you can rein in this problem, because when you order a special diet, they are the ones who shoulder the cost and the hassle.

    • I would greatly appreciate a copy of your allergy policy. I work in a Forensic State Hospital which has a similar culture to corrections and we are frustrated with the lack of guidance on addressing all the “reported” allergies. We are working on developing a policy now. Thank you!

  7. I am a Clinical Operations Supervisor at a Provincial Correctional facility in Nova Scotia, Canada. We have 25 – 35 % of inmates (approx. 120 total pop. ) reporting allergies. I would appreciate your medical diet, allergy diet policy. Thank you.

  8. lam a clinical nurse manager in as juvenile detention centre and I would be be bery appreciative if you can forward any policies and procedures that you have for dealing with allergic reactions.
    Many thanks

    • Unfortunately, I don’t have a policy for dealing with allergic reactions, Fiona. When I write one, I’ll forward it to you!

      • Thank you Dr Keller.would it be possible to me the allergy diet policy and procedure please?
        Many thanks.

  9. Please send me a copy of your medical diet allergy policy. I work at a Forensic Treatment Center and and get many alleged food allergies, and most are food preferences.

  10. I am the nurse at a county jail and we definitely have an issue with reported allergies. And some are just as silly as some of the stories described in the article. Can you please send me your policy on allergies? Some guidance is much needed and appreciated!!

  11. I work in a county jail in a rural area with no hospital in the entire county. We have a doctor who provides care once a week. And right now we have an entire pod that has special diets of some sort. Can you please send me your policy on allergies? We would appreciate your help in this matter.

  12. I am a Medical Coordinator in a county jail and we definitely need to have a policy regarding food allergies and allergy testing. I came across this post and am thrilled that you have addressed this issue. Please do send me a copy of your policy and procedure for allergy testing and food allergy testing. I love this site. You address the many issues in such a realistic and practical manner. So refreshing to see.

  13. Can you please send me a copy of your food allergy policy??!! Our facility needs a policy ASAP. I feel like almost everyone who books in now has some sort of “allergy”. Thanks!

  14. I would appreciate a copy of your allergy protocol and policy. This seems to be rappant in the correctional world! Thank you in advance!

      • I just found this website and I am loving it! I am a Nurse Practitioner at a county jail that houses roughly 800-1000 inmates on average. We deal with food allergies a lot, and are even having issues now with Kosher diets. We currently have an inmate who was refusing trays because we could not prove to him that his food was being prepared properly in a separate kitchen area with its own sink. I would love to see your policy on food allergies as well. I have never seen so many soy allergies in my life as a nurse practitioner until I started practicing at the jail….

        • My opinion: Kosher diets are not a medical issue, they are a religious preference. Complaints about the quality of the kosher diet should not go through medical. You should not be involved in that dispute–unless the patient is staging a true hunger strike. I will send you the sample allergy protocol forthwith

  15. Hi Dr.Keller
    Please may l have a copy of your allergy policy and procedure and any information you have that would be helpful in juvenile detention
    Many Thanks

  16. Thank you, Dr. Keller, for your interesting topics and information. I am also interested in receiving a copy of your policy relating to allergies. Thanks! Kathi

  17. would love to have a copy of your allergy testing and policy/ procedure, could you please email it to me, thanks muchly!

  18. I would like to have a copy your policy and procedure. This article was written a long time ago and this this still very relevant. “Allergies” are one of the biggest headaches our medical and food service departments deal with and unfortunately distract from those that truly need a carefully planned medical diet.

  19. I would LOVE to have a copy of your policy and procedure! We run about 33% with special diet trays. The kitchen staff is not very happy with medical here!! We are in a resort town, so we get all kinds of visitors to our fair city that break the law. I think this would be very helpful!

  20. Ou county jail has a population of approximately 585 inmates, of that on today’s diet roster 97 were on some type of special diet. This seems to be an everyday issue with our population that once they get to the dorms that they talk about “special” diets and we have multiple sick calls in regards to this daily. I would love to have a copy of your allergy policy as well as a diet policy in general if you have one. We are currently in the process of updating our policy and procedures, I think this would make a big impact on our special diet rosters.

    • Thank you for sharing your knowledge with us. Our facility has also experienced a special diet utilization issue!It has become an energy consuming debate amongst correctional versus medical staff on whether to implement RAST testing (i.e. risk of needle sticks, overloading clinical staff, etc.) versus a diet menu driven response (i.e. vegetarian for meat related ‘allergies’ & bland diet for onions, tomatoes, etc.). We would be extremely grateful for any policies & procedures or materials you could provide relating to special diets, and any related menus relating to vegetarian and bland diets if utilized. We have scoured the internet for the latter option with minimal useful results. If you ever again hold another conference in Salt Lake City or elsewhere, please so advise. Looking forward to seeing your presentation at NCCHC conference in Las Vegas!

  21. Please send me a copy of your allergy protocol. Great article! We are having issues at my jail with “alleged” soy allergies.

  22. Pingback: Sample Food Allergy Guideline | Jail Medicine

  23. Serious food allergies are rare, while intolerance of many common foods – from dairy products to gluten in bread – is increasing. Are we in the midst of a health craze or something more complicated?

  24. Hi we have the exact same problems in Australian prisons! Our problem is alleged fish allergies. Apparently they all have had anaphylactic reactions and have responded to NO medical treatment and never went to any dr or hospital for follow up!! What terrible mothers they all must have!

    May I please have a copy of your allergy policy?

  25. Hi, I work in correctional centres and this is an ongoing issue. Would I also be able to have a copy of your policy? Thank you

  26. The issues discussed here exemp;ify the clear need for collection of past medical history. When an individual ‘claims’ a food allergy there should be some previous documentation in the community. Based upon that, allergy diets become less trouble. Truthfully, peanuts & shellfish are given a straight pass through – as they are uncommon on the menu. One of the bigger issues is milk – claims of a lactose intolerance. The usual response is – don’t drink it; there are plenty of other fluids (ex. water). There is no need for substitution. Another ‘tip’ – check the commissary – if an allergy claim is present and the person is getting commissary goods with that item included – so much for the allergy.

  27. Pingback: آلرژی غذایی: جدا کردن حقیقت از داستان - مجله خبری مد و استایل - مد و استایل

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