Food Allergy Counseling

Food Allergy Counseling
Sloane Miller, Food Allergy Counselor (Picture © Noel Malcolm 2013)

Tuesday, July 15, 2014

Food Allergy Counseling: Interview with Dr Dave Stukus, Food Allergy & Casual Contact

I’ve had the honor to feature Dr Dave Stukus (@allergykidsdoc) on my blog before, about food allergy myth and facts. This time I asked him to explore casual social contact with food allergen[s]. The basic question is what is the real risk of casual contact to a severely food allergic person, if any, and as always, how does one manage food allergy exposure risk while living their best and fullest lives?

Nota Bene: The answers below are not meant as a substitute for a thorough conversation with your medical health provider about your personal medical questions and needs. If you would like further support around your food allergy diagnosis, contact me about a tailored-to-you short-term coaching program to increase your confidence whilst managing risk.

***

Allergic Girl:  How do allergens interact with the body to create symptoms?

Dr Dave Stukus: Allergens are proteins that are present inside food, medication, dander, pollen, etc.. Any protein can essentially become any allergen, but some are much better at it than others. We all encounter allergens throughout our environment on a continual basis but they only provoke symptoms in people who have already formed an allergy antibody, called IgE towards that allergen. In people who have allergies, IgE is formed against specific allergens and becomes attached to the allergy cells throughout the body, which are called mast cells. If an allergic person with pre-formed IgE towards a specific allergen then encounters that allergen through touch, inhalation, or ingestion, the allergen can bind to the IgE and cause the mast cells to open. The chemicals inside mast cells, mainly histamine, then cause the symptoms of an allergic reaction. 

AG: What are the other ways allergens can get into our bodies?

DS: Aside from ingestion, food allergens can enter the body and interact with IgE through the skin, mucous membranes, or respiratory tract. It is extremely important to note that risk of a serious, rapidly progressive allergic reaction (anaphylaxis) towards foods mainly occurs after ingestion, with very few exceptions. Casual contact with food allergens is much more likely to cause localized symptoms such as rash, itching, or swelling on the body part that contacted the allergen. People who suffer from eczema or asthma are at particular risk of localized reactions from food allergens as their skin and respiratory tract barrier is often damaged and easily penetrated by allergens and irritants in the environment. Some food proteins, particularly fish, can become aerosolized during cooking/frying and can also cause allergy symptoms, especially coughing and wheezing. (Sharp MF, Lopata et al. Fish allergy: in review.Clin Rev Allergy Immunol. 2014 Jun;46(3):258-71 Most food allergens/proteins, including peanut, do not become airborne very easily, especially in a large enough amount to provoke an allergic reaction.

AG: What is the real risk with cross contact on hard surfaces and non-mucous membranes (non-eczema hands touching doorknobs with nut dust, for example)?

DS: The scientific evidence is relatively lacking in regards to studies with various surfaces but a few important studies have demonstrated that risk for anaphylaxis is low. (Simonte et al J Allergy Clin Immunol 2003; 112: 180-2) Some studies that utilize very sensitive detection devices have demonstrated that peanut protein can be found in very minute quantities on various surfaces, including tables and floors/carpeting inside homes. (Brough et al. J Allergy Clin Immunol 2013;132:623-9) However, the amount of peanut protein is extremely small and unlikely to cause a reaction. In addition, the amount of airborne peanut protein in these studies is significantly lower, meaning that risk from just walking around is even lower.

AG: What about shaking hands? What about spitty talkers? What about subway or bus railings? What about contact sports or contact with communal sports balls?

DS: These can all potentially transmit minute amounts of food allergen but generally not enough to cause any allergic symptoms, especially anaphylaxis. In general, risk of reaction from these sorts of interactions is very low. Obviously, if someone can see food on a particular surface, this would greatly increase the risk of transmission of that particular food allergen.

AG: So, for example, if you see someone eating roasted cashews at a social function, and you are introduced and they extend their hand to greet you, and you don’t feel you should decline, what should the next step be for you to protect yourself, assuming you are tree-nut allergic and can't run to the Ladies Room to wash your hands immediately after such a hand-shake?  

DS: If you know that there will be contact with a known allergen, it is best to try and avoid contact altogether. A friendly disclaimer along the lines of “I’d love to shake your hand, however, I have a xyz allergy and noticed you eating that food just now. I certainly don’t want to offend you, but would rather not risk any contact with xyz allergen. Thank you so much for your understanding.” If circumstances do not allow for prevention, and you have already shaken hands, then definitely try to avoid touching any other body parts, especially the face to try and avoid spreading allergen. Wiping hands on a clean napkin may help but ideally, a good hand washing with soap and water is in order.

AG: Does soap and water really do it?

DS: Soap and water is the best way to remove allergens from skin as well as hard surfaces such as counter tops, dishes, and silverware. Hand sanitizer and plain water are not effective.

AG: What is the best soap and water hand-washing method? 

DS: At least 30 seconds of good soap lather and rubbing the skin before washing off with water is recommended.

AG: How dirty (germs, microbes, virus, antigens, allergens) are our hands on any given day?

DS: Our hands are filthy! In addition to the dirt or other particles visible to the naked eye, there are thousands of microscopic viruses and bacteria present as well. Our skin serves as the body’s first line of defense and most important part of the immune system. It protects us extremely well from all of the germs and allergens that we all encounter on a continual basis. However, touching those same disgusting hands to our face and mucous membranes inside our eyes, nose, and mouths can transmit viruses and allergens very easily. 

AG: What would be the likeliest outcome in an ice cream laced fingers nose-picking scenario, for a diary allergic person, for example?

DS: Areas of the face that are touched by known allergen can produce localized symptoms, including irritation, itching, rash, swelling, runny nose, watery eyes, sneezing, and congestion.

AG: What is a real scenario where the casual risk is real, for children?

DS: The most important scenario is the school setting, particularly in rooms where food is served such as cafeterias. With dozens of children eating all sorts of different foods, it is exceptionally challenging to ensure that food particles and allergens are not left behind on surfaces or accidentally passed to clothing or bookbags.

AG: What is a real scenario where the casual risk is real, for adults?

DS: The best example is flying on commercial airplanes. There are many reports of in flight reactions, with anaphylaxis occurring in up to 1/3 of all reactions.(Greenhawt M et al. J Allergy Clin Immunol Pract. 2013 Mar;1(2):186-94) This is not believed to be due to airborne food allergen, but from contact with seats, pillows, seat trays, etc. The universal theme with almost all cases of reported anaphylaxis is lack of use of epinephrine, either due to no availability or improper recognition/treatment. The focus should be on preparation and awareness rather than fear of risk from unlikely sources of contact. However, there are a few steps passengers can take to help mitigate risk, including wiping the tray table with a cleaning cloth, avoiding use of airline supplied pillows and blankets, and packing one’s own food.

AG: What are some scenarios where the casual contact risk is low to none for anyone?

DS: Most public venues are generally safe either due to lack of any appreciable allergen being present in the first place, or due to low risk of transmission. This includes movie theaters, public transportation, stadiums, parks, and playgrounds. Common sense must prevail and if someone has left behind a particular food allergen on a surface (peanut shells on the next seat), then the risk increases.

AG: What is the best way to manage casual contact risk while maintaining quality of life?

DS: First and foremost, understanding that the risks are minimal, especially in regards to casual contact causing anaphylaxis can go a long way in improving quality of life by reducing anxiety. Preparation with an accurate diagnosis and immediate access to epinephrine autoinjectors is also vital in providing peace of mind.

AG: How can we reduce risk, overall?

DS: With so many potential food allergens and so many environments to consider, it is impossible to remove allergens completely. The fear and concern about casual contact causing a food allergy reaction is much greater than what the actual risk appears to be. Instead of focusing on low risk situations such as door handles, railings, hand shakes, etc, energy would be better served to focus on more effective risk reduction measures. This includes communicating food allergy risk with food handlers at restaurants, school personnel, and places of employment. In order to communicate one’s risk effectively, they must have a good understanding of what foods they need to avoid and how to treat any symptoms due to accidental ingestion of a food allergen. The best place to start this discussion is with one’s personal allergist or primary care physician. 

AG: As we can't wash our hands every minute, what else can we do?

DS: Be prepared! It is unreasonable to attempt to completely eliminate risk. It is also unreasonable to never leave one’s house and avoid contact with the outside world due to concern about a risk that may not be present in the first place. That is why it is so important to stay prepared with an accurate diagnosis, up to date treatment plan, and always have immediate access to self-injectable epinephrine. The deaths and serious allergic reactions from food allergies occur with ingestion of the allergen and lack of available epinephrine.

The vast majority of people with food allergies live enjoyable lives with few restrictions in regards to places they can visit or activities they can partake in. By far, the greatest risk from food allergies comes with accidental ingestion and this should be addressed at every single meal or snack.  

***

Thank you for your insightful and helpful answers, Dr Stukus!

Here is more about Dr Stukus. Follow him on Twitter.




Biography: David Stukus, MD, is board certified in Allergy/Immunology and is an Assistant Professor of Pediatrics at Nationwide Children’s Hospital and The Ohio State University in Columbus, Ohio. His clinical and research interests focus on asthma, especially improving education and adherence for patients and families. As part of his research, Dr. Stukus has created novel technology and educational tools using mobile health apps to improve the care of patients, for which he was recognized with the Nationwide Children's Hospital Department of Pediatrics Junior Faculty Award in November 2013. In addition to being Co-Chair for the planning committee of the Annual Pediatric Asthma Conference, he is also director of the High Risk Asthma Clinic, and Physician Champion for the Easy Breathing Program.

Friday, June 27, 2014

Food Allergy Counseling: Adults with Allergies blog, Anaphylaxis Canada




My esteemed colleagues at Anaphylaxis Canada have launched a blog for adults with food allergies. From their website:

Kyle Dine, who manages the blog for Anaphylaxis Canada, explained: ‘Many websites and resources are aimed at parents of allergic children. We want to, however, make sure everyone affected by food allergies has support and access to relevant information on topics that are important to them.’ The blog covers situations that allergic adults can appreciate such as food allergies and relationships, allergies in the workplace, alcohol ingredient labeling, international travel, and lifestyle articles such as food allergies and pop culture.”

You know Kyle, right? He’s an allergy educator and musician and together we sang this song about how "Allergies Don't Need To Stop You!" 

He kindly asked me to write something for their new blog and here it is live.

Please, spread the word. And spread the link!

Wednesday, June 25, 2014

Recipe: Pasta with Lemony Arugula

Rice pasta, arugula and lemon
After a long day filled with food allergy coaching client sessions and meetings and an evening out with friends at an art opening at a very cool venue, I arrived home, starved and dinner was unplanned. Add to this that I had an oral allergy syndrome reaction to something I ate at lunch (probably the raw tomatoes and bell peppers). So my mouth needed something non-nightshade based, something way safer on what was clearly a high pollen day. 

My fridge was filled with stuff for salad (like more peppers and tomatoes) and the huge box of arugula. In the back was one portion of pasta still in the bag. And I had a bunch of lemons in the bin. 

A hop over to Google and I found two easy recipes, one from Epicurious and one from Martha Stewart that I quickly combined to create my own. In the time it took to make the pasta (about ten minutes), voila! Not only was dinner done but I had a delicious, vegan, light, non-oral allergy syndrome inducing delight.

***

Rice Pasta with Lemony Arugula
Adapted from Epicurious & Martha Stewart

Ingredients
1 portion safe-for-you pasta, dry
Splash of olive oil like Lucini EVOO
1-3 gloves sliced garlic (as desired)
Juice and zest from one lemon (organic if available)
Handful of baby arugula (or any greens you have on hand, kale, spinach, broccoli)
Accompaniments: freshly grated Parmigiano-reggiano, sea salt, freshly ground pepper, squeeze of lemon, red pepper flakes

Preparation

Cook safe-for-you pasta in a large pot of salted boiling water until al dente. Drain BUT reserve some of the cooking water. In same pot, heat oil and sautĂ© garlic on low heat until fragrant. Add lemon juice, zest, salt, pepper and pasta water. Bring to a gentle simmer, reduce heat and simmer 3 minutes. Add the handful of greens to the lemon and EVOO “sauce” and stir until bright green and warmed through. Add pasta. Stir until mixed. Adjust for seasoning. Transfer pasta to your dish. Top with additional grated Parmigiano-reggiano, a light sprinkling of sea salt and freshly ground pepper and a squeeze of lemon juice, if desired.

Variation
I added a variation the other night: butter beans with lemon, EVOO, salt & pepper on top. Oh yum!

Vegan, easy. yum!

Monday, June 23, 2014

Allergic Girl & Social Media: Allergic Girl Facebook Posts

I noticed recently when I held an Allergic Girl Facebook Page contest, I had to re-run it, The winners didn’t respond to my messages that they won, no matter how many times I Facebook emailed or tagged them. What exactly was going on with Facebook? 

I had heard about Facebook's new changes to fan pages like my Allergic Girl Facebook Page but it wasn't until this recent contest, I began to see the evidence of it. And then I read Erin Smith of Gluten-Free Fun’s blog post which led me to a Derek Halpern article. (Big shout out to fellow blogger and incredible celiac disease advocate Erin Smith for her blog post on this issue.)

Facebook wants me to pay for you to see my Allergic Girl Facebook Page status updates when they used to be free

Here are some things YOU can do to ensure YOU are getting my regular Allergic Girl Facebook Page updates. And if, for example, you won a contest, you’d get the notification!

1. Make sure to Like my Allergic Girl Facebook Page and check the Get Notifications tabHave a look at what I mean below. This is crucial.


2. Follow me on Twitter. I post on there a lot and very often link back to my Allergic Girl Facebook Page.

3. Sign up for my free newsletter where I post free content, contests for free great stuff and very often link back to my Allergic Girl Facebook Page.

I hope this helps those contest winners see that they won!

As always, thank you for your readership, support and Allergic Girl Facebook Page "likes"!

Friday, June 20, 2014

Food Allergy Counseling: Eater.com, "How Restaurant Pros Are Handling the Surge of Food Allergies"

Gluten-free, nut-free & fish-free pasta at Maialino


Eater National published an excellent profile of how one restaurant in Austin, Texas called Odd Duck is striving to handle patrons dietary needs when it comes to severe life threatening food allergies, celiac disease and a host of other medical needs. They profile several restaurant groups and leaders in the field, including me! Have a read here.

Thank you to Amy McKeever and Eater.com for this excellent job tackling a complex issue.

***

Want to know how I dine out safely and often?

1. Check out my book: Allergic Girl: Adventures in Living Well with Food Allergies (Wiley, 2011).
2. Read out this article in Allergic Living magazine.
3. Contact me for a more personalize program of lifestyle coaching around dietary restrictions.





Friday, June 13, 2014

Food Allergy Counseling: Custom Chef Cards


A recent food allergy coaching client of mine showed me the chef card she created for her son, who is allergic to dairy and sesame. 

She gets compliments on it all the time from chefs. They love it. And I can see why. Courteous, clear and direct; it opens doors and opens up conversation.

How are you communicating with restaurants about you or your loved one with food allergies about your needs and dietary restrictions?



Tuesday, June 10, 2014

Product Review: King Arthur Flour Gluten-Free Doughnut Mix


When I was little, there was a butcher store near our country home called Dressen’s that my parents would take me to for powdered doughnuts  - the deep fried variety. I have very specific food memories of their texture and taste: fresh fluffy cake, with a deep fried edge of brown dough, covered in layers of powdered sugar was so thick, it would get everywhere. Part of a child's delight. In the same area, there was another doughnut that competed for my attentions: the apple cider doughnuts made at the Milk PailThere were sold in a pack of a dozen, in a plastic bag, also light and cakey, with the deep brown deep fried crust and color. But no powered sugar. I liked them equally.

In 2000, when I was still eating wheat (I’ve been wheat free since 2005 due to an intolerance), my then boyfriend (Henry in my book: Allergic Girl) would bring me boxes of Krispy Kremes. Wow, did I love those – deeply vanilla scented dough, not cakey but soft and sweet with a slick white vanilla glaze. We’d inhale half a dozen before we even got home. 

However, I haven’t had a wheat-based doughnut since 2005. Really. So, when I saw one of my favorite allergen-friendly companies, King Arthur Flour came out with a doughnut mix, I had to try. King Arthur Flour was kind enough to send me samples to try and try I did.

Here’s the ingredient labelI made the recipe as directed, using Organic Valley organic butter and Organic Valley organic lactose-free 2% milk.

The cake was light and yellow with an excellent crumb. It reminded me of Dressen's doughnuts without the deep fried crust. It even smelled doughnutty. The texture wasn’t grainy or dry, which can happen with GF. It was moist, light. And even though baked, tasted decadent.




Since I haven’t eaten wheat regularly since 2005, my taste buds have changed. So, I gave doughnuts to two wheat-eaters, who devoured the samples. They said it tasted very close to the real thing and they would happily serve to guests. I gobbled three during taste testing and then two after lunch yesterday. 

Irresistible is my verdict!

Thank you, King Arthur Flour for making another hit.

***

A note about allergens: King Arthur Flour Gluten-Free regularly tests for gluten in their dedicated facility. This facility is also free from the top 8 allergens, however they do not test for any allergens outside of wheat. If you have questions about your needs, please contact them directly.

Monday, May 26, 2014

Food Allergy Counseling: Get Schooled in Anaphylaxis™, Camp Checklist: Mylan

Summer camp is around the corner. Have you had The Food Allergy Talk with the camp and your child about managing food allergy risk while having a great time?  Here's some assistance in the form of a helpful graphic from Mylan Specialty L.P., marketers of EpiPen:

"Check out the below Get Schooled in Anaphylaxis™ camp checklist to ensure all camp staff and campers are aware and prepared for anaphylaxis. The camp packing list should include your action plan, which includes avoiding your known allergens and having access to two epinephrine auto-injectors should anaphylaxis occur."




Have more questions about managing food allergy risk? Check out Anaphylaxis101.com for lots of free downloadable information and talk to your board certified medical provider about your child’s food allergy risks, needs and anaphylaxis action plan.

Friday, May 23, 2014

Food Allergy Counseling: Chef The Film

I love film and I love food, so films about food are an extra delicious pairing to me. Like peanut butter and marshmallow fluff sandwiches. (PS you can make "fluffernutters" with all kinds of food allergy free variations like using Ricemellow Creme & Soynut butter on Udi's GF bread. Yum!) 

Chef, written and directed by Jon Favreau, is just that: a delicious pairing of great music, a road trip movie, father/son bonding story and gorgeous food pictures. 







For example, here's Chef's pasta aglio e olio recipe posted on She Knows and Bake SpaceChef makes this, read seduces, Scarlet Johansson with this recipe. And you can totally make this top 8 allergen, food allergy friendly; it's naturally tree-nut free! 

If you see Chef, make sure to stay until the very end of the credits as there is footage of Chef Roy Choi talking to Jon Favreau about making the perfect grilled cheese. Here's some of the background footage through Youtube. So fun! 

Interestingly, how chefs are represented in this film (and most food/chefy films I can think of, like Mostly Martha or Eat Drink Man Woman) underscores something I understand about chefs: they often express love through cooking. Jon Favreau said as much to Eatocracy when he was explaining some of what he learned working with Chef Roy Choi (Tweets by Chef Choi) to get this role down correctly: “…The most accurate, sincere communicating [chefs] do is through their food.”

Understanding this basic tenant of chef-life is how I can dine out often. I know, at the core, chefs are driven to express themselves, their passions and their art through food. Possibly harming through food is the exact opposite of what drives culinarians as professionals and artists.

When you communicate with a chef clearly about your food allergic needs, odds are your needs will be taken seriously and appropriate accommodations will be made. Here’s my step-by-step guide to dining out (via Allergic Living Magazine).  I have a whole chapter about dining out in my book Allergic Girl: Adventures in Living Well with Food Allergies (Wiley, 2011) or if you want to work on creating food allergy confidence around challenges like dining out, contact me for a tailored-to-you counseling program.

Monday, May 19, 2014

Food Allergy Counseling: Allergies Don’t Need To Stop You, Kyle Dine

Me and Kyle Dine in Central Park

Colleague, friend and fellow adult with food allergies, Kyle Dine, is an allergy educator and musician. He works with Anaphylaxis Canada and he tours the United States singing to school assemblies, helping children, with and without food allergies, learn how to be better advocates for their health. You can book him for your school hereYou can also read his blog post about our fun day here

I am a sponsor of his latest tour,  Let’s Go Nuts. As part of my sponsorship package we decided to do a video together about food allergy awareness. Our song is: "Allergies Don’t Need To Stop You". Which is totes true. We are living embodiments.

This is some classic Kyle Dine singing with yours truly, Allergic Girl

Feel free to like it, share it and sing it with your kids.




***

Allergies Don’t Need To Stop You
 © Kyle Dine & Sloane Miller

I'm an Allergy girl

And I'm an Allergy Guy
I can do almost anything
And I'm willing to try

I can jog in Central Park

I can play sports and the guitar
So we have a couple allergies
Doesn't mean we can't go far.

I can eat safely at a restaurant
I'll make the reservation, what food do you want?
I can climb a mountain, be on top of the world!
I can make new friends  
You’ve got one in this girl!

I'm an Allergy girl
And I'm an Allergy Guy
I can cook nearly anything
And I'm still... willing to try!

I can live in the big city
I can live in the countryside
Wherever we'll be, allergy free
Is possible for you and I

I can read a label like I'm reading a book
But you gotta double check, here I'll give it a look
I can draw, paint, build, camp, dance [and sing
It's cool to know we can do anything

I'm an allergy girl
And I'm an allergy guy
And whether you're young or old
Whether you have many or few
Allergies, don't need to stop you!

Or me, or you, or him or her, or any of you!

***

Thank you, Kyle, for a wonderful afternoon of laughter and song!