On behalf of the 32 million (1 in 10) Americans who suffer from life-threatening food allergies, and the 85 million (1 in 4 households) that are directly and indirectly affected by food allergies and/or intolerances to one of the top nine food allergens, the undersigned members of the Food Allergy Collaborative appreciate the opportunity to submit the following comments toward the fall 2022 White House Conference on Hunger, Nutrition, and Health.
Launched in 2019, the Food Allergy Collaborative is an alliance of advocacy organizations, those living with food allergies, and industry partners who are uniting to advance effective, patient-centered initiatives in food allergy awareness, research, and care. Our vision is to create lasting, system-wide change for the food allergy community. Bringing everyone to the table ensures that we can collectively identify issues in food allergy and create a shared vision to solve them. Together, we can coordinate our efforts to maximize impact.
Our comments below relate to the needs of the food allergy community applicable to four of the five pillars being considered to frame policy recommendations in the upcoming White House Conference. We support using a health equity lens to accommodate the needs of the entire US food allergy community. While our focus is on the needs of the food allergy community, where applicable we also note where policy actions are needed for those with celiac disease and other conditions where medically necessary foods are required for good health outcomes.
What follows is the report of convening of the Food Allergy Collaborative, July 13, 2022, to discuss recommendations to meet the needs of the food allergy community toward the upcoming White House Conference on Hunger, Nutrition, and Health.
Pillar 1 – Improve food access and affordability
There is significant burden on those with food allergy in under-resourced populations. Regardless of socio-economic status, food allergic individuals and families pay more for food that is safe to consume, on average five percent (5%) more than households without food allergy. They also spend more time food shopping, traveling to find allergy appropriate foods, reading labels, contacting food manufacturers, and conducting other research about foods for themselves and their families.
Federal food assistance programs (e.g., SNAP, WIC) must receive adequate funding to provide monthly benefits that keep pace with inflation and the higher costs of allergy safe foods as well as the rising prevalence of food allergic individuals they serve. Federal meals programs (e.g., school, summer meals) must receive adequate funding and reimbursement. All federal food programs must provide appropriate substitutions for those with food allergy and celiac disease. Additionally, policies should be established to broaden foods free of the top nine food allergens and gluten-free options distributed by The Emergency Food Assistance Program (TEFAP).
Food access is often a challenge, and we encourage policies to reduce and eliminate limited access to food retail outlets – both rural and urban – to improve food access, and for food banks and food pantries to support the needs of those with food allergy and celiac disease with appropriate food substitutions. Education about food allergy and food allergy management needs to be available to and used by personnel at food banks and pantries.
Pillar 2 – Integrate nutrition and health
For over 25 years, feeding advice was to avoid the introduction of allergenic foods in infancy and early childhood. The Dietary Guidelines for Americans 2020-2025 (DGA) recommend introducing potentially allergenic foods (e.g., milk, egg, peanut, tree nuts, wheat, soy, fish, crustacean shellfish, and sesame) when other complementary foods are introduced to an infant’s diet to reduce the risk of developing food allergy. The DGA specifically notes that there is no evidence that delaying introduction of allergenic foods, beyond when other complementary foods are introduced, helps to prevent food allergy. Thus, a national standard of care is critically needed so that all relevant health professionals who interface with newborn infants and their parents consistently and uniformly discuss the importance of early introduction of allergenic foods, and move beyond peanut given the rapidly evolving positive evidence for other common allergens when it comes to reducing the risk of allergy development. Early introduction of food allergens in the diets of infants is a public health imperative, as it has the potential to virtually eliminate the development of infant and childhood food allergy within the next generation and the overall burden of food allergy on the individual, schools, and healthcare system.
For those with food allergy, food avoidance is the primary management strategy, which can be difficult for even the most cautious patients. When accidental exposure does happen, epinephrine is a critical tool for treating severe allergic reaction or anaphylaxis, which can be fatal. We believe in and support the development of policies that improve access to epinephrine and reduce its cost. We encourage and support national policies that require epinephrine on all US airlines, in schools, in child-care facilities, and other public settings. Finally, policies need to be established to eliminate the current patchwork of local and state regulations that impede the delivery of epinephrine by emergency response personnel.
Pillar 3 – Empower all consumers to make and have access to healthy choices
For some time, federal child nutrition programs have been required to address food allergy and prevention. Going forward, as information about food allergy and its management evolves, child nutrition program staff must remain current with scientific knowledge about food allergy and top food allergens affecting the US population (milk, egg, peanut, tree nuts, wheat, soy, fish, crustacean shellfish, and sesame).
Related to food allergy, there is a critical need to develop and deliver education in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC program). Both basic information about food allergy and its management, as well as early introduction of food allergens must be provided to WIC Competent Professional Authorities (CPAs) and consistently delivered to WIC participants. This is particularly important to reduce health inequities and the needs of under-resourced populations.
There is a critical need for WIC program food package regulations to be updated to address the needs of children and women with existing food allergy and celiac disease. At present, WIC program food packages for children and women do not include adequate food allergy alternatives in numerous food categories that deliver important nutrients. There needs to be flexibility of options for those with food allergy and celiac disease, and not be constrained by cost or package size. Examples include expanded alternatives beyond soy “milk” for those with milk allergy; retain non-wheat cereals such as corn, rice, and oats; and allow gluten-free bread. For infants, the WIC program food package must evolve to include delivery of top food allergens (see above) to be introduced early in their diet (beginning at 4 months of age) to reduce the risk of developing food allergy. See also recommendations in Pillar 2 regarding availability of food allergy alternatives and options.
Finally, we support accurate food allergen labeling on package and online, stringent attention to food allergen controls by food manufacturers and in food service/restaurants, and urge federal policies to reduce the existing proliferation and voluntary use of precautionary allergen labeling (PAL) statements such as “Not suitable for [X allergen]”, “May contain [X allergen]”, and others. This could be accomplished with a mandate for and funding to the Food and Drug Administration to create an evidence-based standardized and transparent approach for use of PAL statements that benefits those with food allergy.
Pillar 5 – Enhance nutrition and food security research
Federal funding is needed and appropriations to support food, nutrition, and food security research with a health equity lens. This includes adequate funding and appropriations for food allergy research and celiac that requires inclusion of racial, ethnic, and economic diversity that exists within the food allergy community and that seek to address documented disparities and surveillance. Because of the increase in food allergy in recent decades, a national program is needed to collect surveillance data on food allergy, and it must reflect prevalence, severity, and potency among underserved populations.
The undersigned members of the Food Allergy Collaborative thank you for the opportunity to offer these comments and policy recommendations related to the needs of the food allergy community toward the White House Conference on Hunger, Nutrition, and Health. We look forward to continued involvement in the process toward and participation in the fall 2022 Conference.