When her son Javier turned 16, Avina thought that she was done as an allergy mom. Years of worrying about what to cook for Javier, how to take relatives and friends into confidence about what he could and could not eat, and places he could visit or not were finally coming to end for her.

She felt confident that her son could handle his food allergy on his own and navigate through daily encounters which food allergens, consuming which could be fatal for him by causing anaphylaxis.

Until the day she rushed to his school to find him in the middle of a severe allergic reaction. His face was swollen, he was unable to breathe and he was writhing on the floor.

His class teacher was chewing her nails and was crying. She was mumbling something about having read the food advisory warning label before giving Javier a certain brand of confectionary item.

Avina snatched the box from which Javier had eaten. She patiently read each and every detail on the food label but her confusion was only increasing.

There was nothing on it to indicate that Javier, or anyone else, could experience an allergic reaction after consuming it.

What had happened?

Food Labels 

Food Allergies have risen  dramatically over the past few decades. In UK alone, 2% adults and 8% children are allergic to some kind of food while 15 million Americans are currently living with it too.

The only way to manage an allergy is avoiding 8 mainstream food allergens in all food products. Like every other school and household, Javier’s school also brought its grocery from a local store, where the items were purchased from a variety of processed and packaged produce and food brands

This month, the inventory manager had opted for a new brand of confectionary. However, Javier’s teacher was sure that she had read the Nutrition Fact Labels stamped on the packaged foods.

Only to Avina’s and the school administration’s dismay, the label itself was misguiding and confusing.

Many  researchers claim that the current allergy warnings on food products are vague and can even lead to unintentional exposure. The same had happened with Javier.

Many professional nutrition and healthcare experts have voiced their concerns over the grave issue. According to Javier’s doctor, puzzling advisory labels on food packages need to have more clarity and the effectiveness of these labels had to be determined in order to prevent food-induced anaphylactic attack.

“Food labels do warn about allergenic ingredients in a specific product but the food industry uses the nutrition labels as a “safety net” and exploits it to their advantage,” Dr Ramos said, adding that for someone like Javier, it was better to ignore food labels and to only trust products from verified sources.

“For allergic individuals eating a food containing allergen is equal to contamination and therefore not stating the allergic content of food clearlyis equivalent to a criminal act,” Avina’s lawyer told her.

In the US, the Food and Drug Administration (FDA) passed the Food Allergen Labeling and Consumer Protection Act (FALCPA) in 2004 so all food products have to show if their product contains even a negligible quantity of any of the eight food allergens. FALCPA became effective in 2006 and mandates the labeling of the eight major food allergens in the US i.e. milk, eggs, fish, crustacean shellfish, peanuts, tree nuts, wheat and soy. FALCPA also requires food manufacturers to list the warnings in simple language.

Advisory labeling also shows statements such as “May Contain”, “Processed in a facility that also processes so an so,” or “Made on equipment with…” when there is risk of cross-contact of ingredients. However such labeling is voluntary and optional for food manufacturers, and there areno laws which govern the necessity of such testimonials.

The guidelines for food industry manufacturers state that advisory labels “should not be used as a substitute for adhering to current good manufacturing practices and must be truthful and not misleading.” But since this guideline is not compulsory, its effectiveness needs to be gauged.

Allergic consumers heavily rely on food label info to help them dodge exposure to food allergen. Under the US Food, Drug, and Cosmetic Act any edible product misbranded with an undeclared major food allergen is subject to recall, but it is still the most common cause of recall by the FDA.

Likewise, the UK Anaphylaxis Campaign carried out an audit which found out that 69% of all cereals and 56% of all confectionery products in the market only mentioned having ‘traces of nuts’ as an ingredient and did not state if the product actually contained tree nuts and peanuts, both of which are known major allergens.

Many, including Avina, have stressed that the current system is not enough to detect undeclared allergens in foods and appropriate controls were to stop misbranding of food.

In 2012 the FDA’s Reportable Food Registry reported that about 38% of all food recalls were the result of finding undeclared food allergens. Similarly in the UK a study found that 60% of the parents whose children suffered from any form of food allergy did not buy products labeled with “may contain traces”. It was also found that some products use label such as “made in a factory that uses nuts” which meant that cross-contamination could happen because of shared production paraphernalia. Case studies, similar to that of Javier’s, have shown that majority of food allergy attacks or related deaths occur outside homes after consuming foods from unreliable sources. . Similarly, a Canadian study also cited food labeling as a chief influencer of unintentional exposure, adding that about 47% of allergic individuals from a group size of 651 had an allergic attack due to a label issue.

The European Directive legally stipulates listing all of the 14 major allergens in UK on the food listing. Under European standards the allergens include gluten, crustaceans, egg, fish, peanuts, milk, tree nuts, soy, sesame, celery, mustard, lupin, molluscs, and sulphur dioxide or sulphites present in pre-packed foods. However including an advisory statement on the packages is not compulsory. Disapproval for the voluntary labeling of advisory statements is not widely appreciated.

Another risk of exposure to food allergen is posed by negligence on the part of food manufacturers. Cross-contact is an unintentional industrial processing occurrence in which a particular food can come into contact with another food which can result in their proteins mixing together. However, the amounts are so insignificant that they can’t be seen, tasted or smelled but can still cause an allergic reaction. According to the US Food Allergy Research & Education (FARE) organization, the term ‘cross-contact’ is fairly new and is sometimes even referred to as ‘cross-contamination’ in Europe.

Both in the US and the UK there are no legislations to restrict or regulate unintentional and preventablecross-contamination during production. . In the UK, a food manufacturer can only be taken to court on the basis of criminal and civil law if the food product is defective, not because it contains a life-threatening allergen.

Preventive measures to reduce cross-contamination are expensive. For instance,cross-contact with milk white can occur while producing dark chocolate. A UK study even found that 75% of dark chocolate brands which did not list cow’s milk as an ingredient actually did contain milk proteins.

Some food manufacturers are employing tactics to completely evade addressing the food allergy issue by deliberately adding allergens so they can stamp an advisory label and be done with it. The practice further restricts the food choices for allergic consumers. Food safety enforcement officers and food manufacturers have expressed the need to make voluntary advisory labels compulsory but the practice would again limit the choices for allergic individuals.

Some experts also believe that the best solution would be to list the quantity of the allergen present in a food product so that the allergic individual could decide if they can tolerate it or not. However, generating precise data on the exact quantity of allergens and determining an allergy threshold i.e. crossing point which can trigger an allergic attack, is difficult. Food allergy and resulting responses cannot be standardized..

The severity of an allergic reaction is affected by numerous factors. Some people are more susceptible to food allergens and can be labeled as sensitive, while some people do have allergic reactions but their severity is very low.

The denaturation of the allergen by the production processing is another key factor. For instance, if eggs and milk are baked at high temperatures the protein structure of the allergen changes, enabling individuals who are allergic to milk and eggs to consume baked goods e.g. cake, biscuit etc..

Likewise the presence of derived ingredients i.e. specific compounds extracted from particular foods, can be harmless for some while it can activate an allergic response in others. For example food allergies are usually caused by the immunoglobulin E antibodies which are proteins in nature, and products such as soy oil, a lipid, may not be fundamentally proteins but since it is derived from soy it also contains minute amounts of soy proteins. A vast majority of allergic people can tolerate the presence of derived ingredients but a risk of an attack is always present.

Sometimes the activity of allergens is inhibited as a result of chemical and physical interactions between different compounds e.g. proteins, fats, and carbohydrates. The interactions on the molecular level, also known as the food matrix, can alter the induction of allergic outcomes. Not much is known about the mechanisms which can inhibit food allergies when different foods are prepared together.

After evaluating all these options, Avian realized that setting up one standardized and safe threshold for her son was simply impossible.  One possible option is the concept of the lowest observed adverse effect level (LOAEL), a threshold or cut-off level of food allergen which is so low that it will not cause an allergic event in a vast majority of people. However the risk factor for sensitive or highly allergic people always exits. In 2007 the FSA stated “there is a lack of scientific and clinical evidence on which to base firm conclusions regarding the minimum amounts of some allergens needed to trigger adverse reactions in sensitive individuals.”

LOAEL was adopted in the Australian and New Zealand food industry for advisory labeling and in 2007 a standardized risk assessment tool called the voluntary incidental trace allergen labeling (VITAL) was also introduced. The aim of VITAL was to provide simple advisory warnings clearly and its adoption in the US and the UK, would improve the allergy labels system considerably.

Saving her son’s life after the incident at school was not easy and until the FDA came up with better regulations for the food labels, Avina could not be sure if she could take the risk again.